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 B
Explanation
Choice A reason:
Taking cimetidine an hour after antacids is appropriate because antacids can interfere with the absorption of cimetidine. It is recommended to separate the intake of these medications by at least one hour to ensure proper absorption and effectiveness of cimetidine.
Choice B reason:
Decreasing cigarette use to a pack per day is not sufficient for a client with peptic ulcer disease. Smoking has been shown to exacerbate peptic ulcers and hinder their healing process. Complete cessation of smoking is strongly recommended to improve the healing of peptic ulcers and reduce the risk of recurrence.
Choice C reason:
Monitoring for signs of sexual dysfunction is important because cimetidine can cause side effects such as decreased libido and erectile dysfunction. Patients should be aware of these potential side effects and report any issues to their healthcare provider.
Choice D reason:
Notifying the healthcare provider of lethargy is crucial because lethargy can be a sign of a more serious underlying condition or an adverse reaction to the medication. Prompt reporting allows for timely intervention and management.
Correct Answer is C
Explanation
Choice A Reason:
Initiating cardiopulmonary resuscitation (CPR) is a critical action when a patient is in cardiac arrest or not breathing. However, in this scenario, the client is experiencing severe respiratory depression due to opioid overdose, and the first line of treatment is to administer naloxone. If the client does not respond to naloxone, then CPR may be necessary, but the immediate step is to address the opioid toxicity.
Choice B Reason:
Preparing to assist with chest tube insertion is not relevant in this context. Chest tubes are typically used to treat conditions like pneumothorax or pleural effusion. The client’s symptoms are due to opioid-induced respiratory depression, which requires naloxone administration rather than chest tube insertion.
Choice C Reason:
Administering a second dose of naloxone is the appropriate action. Naloxone is an opioid antagonist that reverses the effects of opioid overdose, including respiratory depression. Given the client’s critically low respiratory rate and oxygen saturation, a second dose of naloxone is necessary to counteract the opioid effects and restore normal breathing.
Choice D Reason:
Determining the Glasgow Coma Scale (GCS) score is useful for assessing the level of consciousness, but it does not directly address the immediate need to reverse the opioid-induced respiratory depression. The priority is to administer naloxone to improve the client’s respiratory status. Once the client is stabilized, further assessments, including the GCS score, can be conducted.