The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?
Count the apical and radial pulses simultaneously.
Observe for edema around the ankles.
Auscultate the client’s bowel sounds.
Measure the client’s capillary glucose level.
The Correct Answer is C
Choice A reason:
Counting the apical and radial pulses simultaneously can help detect pulse deficits, which may indicate cardiac issues. However, this is not the most critical assessment for a client receiving hydromorphone.
Choice B reason:
Observing for edema around the ankles is important for assessing fluid retention and potential heart failure. While relevant, it is not the primary concern for a client on hydromorphone.
Choice C reason:
Auscultating the client’s bowel sounds is crucial because hydromorphone, like other opioids, can cause constipation and potentially lead to paralytic ileus, a serious condition where the intestines stop moving food through. Monitoring bowel sounds helps detect early signs of this complication.
Choice D reason:
Measuring the client’s capillary glucose level is important for diabetic patients or those at risk of hyperglycemia. However, it is not directly related to the administration of hydromorphone.
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Correct Answer is C
Explanation
Choice A Reason:
Checking for the correct placement of the patch behind the client’s ear is important to ensure proper administration of the medication. However, this action does not address the client’s concern about pain relief. Scopolamine is used to prevent nausea and vomiting, not to manage pain. Therefore, while correct placement is necessary, it does not explain why the client is still experiencing pain.
Choice B Reason:
Offering to apply a new transdermal patch to relieve the pain is not appropriate because scopolamine is not intended for pain relief. Applying a new patch would not address the client’s pain and could lead to unnecessary medication use. The nurse should clarify the purpose of the medication instead.
Choice C Reason:
Explaining that the medication is not given to prevent pain is the correct action. Scopolamine is an anticholinergic medication used to prevent nausea and vomiting associated with motion sickness and recovery from anesthesia. It is not an analgesic and does not provide pain relief. The nurse should inform the client about the intended use of the medication and address pain management separately.
Choice D Reason:
Advising the client that the effects of the medication have worn off is incorrect. Scopolamine patches are designed to release medication over a period of up to 72 hours. The effects would not wear off within a few hours. This statement does not address the client’s misunderstanding about the purpose of the medication.
Correct Answer is B
Explanation
Choice A Reason:
Photosensitivity is not a common side effect of gabapentin. While some medications can cause increased sensitivity to sunlight, gabapentin is not typically associated with this issue. Therefore, it is not a primary concern that needs to be reported to the healthcare provider.
Choice B Reason:
Rapid weight gain is a significant side effect that should be reported to the healthcare provider. Gabapentin can cause fluid retention and swelling, which may lead to rapid weight gain. This can be a sign of more serious underlying issues, such as heart or kidney problems, and requires prompt medical attention.
Choice C Reason:
Gastric irritation, such as nausea or upset stomach, can occur with gabapentin use but is generally not severe. While it can be uncomfortable, it is usually manageable with supportive care and does not typically require immediate reporting to a healthcare provider unless it becomes severe or persistent.
Choice D Reason:
Sexual dysfunction is not commonly associated with gabapentin. While some medications can affect sexual function, gabapentin’s side effects are more commonly related to the nervous system, such as dizziness, drowsiness, and coordination issues. Therefore, this is not a primary concern that needs to be reported.
