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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A reason:
Instructing the client to obtain a prescription for oral terbinafine is the most appropriate action. Oral terbinafine is an antifungal medication that is effective in treating fungal infections of the toenails. It works by inhibiting the growth of fungi, leading to the resolution of the infection. Topical treatments are often insufficient for toenail fungal infections because they do not penetrate the nail bed effectively.
Choice B reason:
Advising the client to obtain a prescription-strength formulation of the ointment is not the best approach. While prescription-strength topical antifungals can be more effective than OTC options, they still may not penetrate the nail bed adequately to treat the infection. Oral antifungals are generally more effective for toenail infections.
Choice C reason:
Suggesting that the client use the ointment twice a day to be more effective is not recommended. Increasing the frequency of application of an ineffective treatment is unlikely to yield better results. The client needs a more effective treatment option, such as an oral antifungal.
Choice D reason:
Reassuring the client that treatment of fungus-infected toenails often takes several months is true but does not address the issue of using an ineffective treatment. While it is important to set realistic expectations about the duration of treatment, the client needs to be directed towards a more effective treatment option.
Correct Answer is A
Explanation
Choice A reason:
Taking sucralfate on an empty stomach at least 1 hour before meals is crucial for its effectiveness. Sucralfate works by forming a protective barrier over ulcers, and food can interfere with this process. Therefore, it is recommended to take sucralfate on an empty stomach to ensure maximum efficacy.
Choice B reason:
Administering an additional dose if a dose is missed is incorrect. If a dose is missed, it should be taken as soon as possible. However, if it is almost time for the next dose, the missed dose should be skipped, and the regular dosing schedule should be resumed. Doubling up on doses can lead to potential side effects and complications.
Choice C reason:
Scheduling doses with each meal and at bedtime is not appropriate for sucralfate. This medication should be taken on an empty stomach, not with meals. Taking it with food can reduce its effectiveness in treating peptic ulcers.
Choice D reason:
Continuing with the normal dose schedule after missing a dose is partially correct but lacks the specific instruction to skip the missed dose if it is almost time for the next one. The correct approach is to take the missed dose as soon as possible unless it is close to the next scheduled dose.