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 D
Explanation
Choice A Reason:
Avoiding taking allopurinol on an empty stomach is a common recommendation to prevent stomach upset. Taking the medication with food can help reduce gastrointestinal discomfort, making this advice appropriate and not requiring additional instruction.
Choice B Reason:
Consuming 2 liters of water daily is advised when taking allopurinol to help prevent kidney stones and ensure proper hydration. Adequate fluid intake helps to dilute the urine and reduce the risk of uric acid crystal formation, making this advice correct and not needing further instruction.
Choice C Reason:
Reducing caffeine and acidic intake can be beneficial for individuals taking allopurinol, as these substances can increase uric acid levels and potentially exacerbate gout symptoms. This advice is appropriate and does not require additional instruction.
Choice D Reason:
Doubling the dose if a dose is missed is incorrect and potentially dangerous. Allopurinol should be taken exactly as prescribed, and doubling up on doses can increase the risk of side effects and toxicity. If a dose is missed, the client should take it as soon as they remember, but if it is almost time for the next dose, they should skip the missed dose and continue with their regular schedule. This instruction requires correction by the nurse.
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.