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 A
Explanation
Choice A reason:
Low-density lipoprotein (LDL) is often referred to as “bad” cholesterol because high levels can lead to plaque buildup in arteries and result in heart disease and stroke. Atorvastatin is a statin medication that works by reducing the production of cholesterol in the liver, specifically targeting LDL cholesterol. Lowering LDL levels is a primary goal in managing and reducing the risk of coronary artery disease.
Choice B reason:
High-density lipoprotein (HDL) is known as “good” cholesterol because it helps remove other forms of cholesterol from the bloodstream. While atorvastatin can also help increase HDL levels, the primary indicator of its effectiveness in reducing the risk of coronary artery disease is the reduction in LDL levels.
Choice C reason:
Prothrombin time (PT) is a measure of how long it takes blood to clot. It is not directly related to the effectiveness of atorvastatin in managing cholesterol levels or reducing the risk of coronary artery disease. PT is more relevant in the context of anticoagulant therapy.
Choice D reason:
Creatine phosphokinase (CK) is an enzyme found in the heart, brain, and skeletal muscles. Elevated CK levels can indicate muscle damage, which can be a side effect of statin therapy. However, CK levels are not used to measure the effectiveness of atorvastatin in lowering cholesterol or reducing the risk of coronary artery disease.
Correct Answer is B
Explanation
Choice A Reason:
While monitoring temperature is important for overall health assessment, it is not the most critical vital sign to check first in the context of opioid-induced lethargy. Opioids primarily affect the respiratory system, and respiratory depression is a significant risk. Therefore, temperature is not the priority in this scenario.
Choice B Reason:
Respiratory rate is the most critical vital sign to check first. Opioids can cause respiratory depression, which can be life-threatening. A decreased respiratory rate is a key indicator of opioid overdose or severe side effects. Monitoring the respiratory rate allows the nurse to assess the severity of the respiratory depression and take immediate action if necessary.
Choice C Reason:
Pulse rate is also an important vital sign, but it is secondary to respiratory rate in this context. While opioids can affect heart rate, the immediate concern with opioid-induced lethargy is respiratory depression. Therefore, checking the respiratory rate takes precedence over the pulse rate.
Choice D Reason:
Blood pressure is another vital sign that should be monitored, but it is not the first priority in this situation. Opioids can cause hypotension, but the primary and most immediate concern is respiratory depression. Therefore, the respiratory rate should be assessed first to ensure the client’s airway and breathing are adequate.