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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View Related questions
Correct Answer is C
Explanation
Choice A Reason:
Reports of increased energy levels and decreased fatigue are subjective indicators of improvement in anemia symptoms. While these reports are important and suggest that the client is feeling better, they do not provide objective evidence of the effectiveness of epoetin alfa. Hemoglobin levels are a more precise measure of the medication’s impact on anemia.
Choice B Reason:
A food diary showing increased consumption of iron-rich foods indicates that the client is making dietary changes to support their anemia treatment. However, this does not directly measure the effectiveness of epoetin alfa. The medication’s primary goal is to stimulate red blood cell production, which is best assessed through hemoglobin levels.
Choice C Reason:
An increase in hemoglobin level to 12 g/dL (7.45 mmol/L) is an objective indicator that epoetin alfa is effective. Hemoglobin levels are a direct measure of the red blood cell count and oxygen-carrying capacity of the blood. An increase in hemoglobin levels indicates that the medication is successfully treating the anemia associated with CKD.
Choice D Reason:
Taking concurrent iron therapy without adverse effects is important for overall treatment adherence and minimizing side effects. However, it does not directly indicate the effectiveness of epoetin alfa. The primary measure of effectiveness is the improvement in hemoglobin levels.
Correct Answer is A
Explanation
Choice A reason:
Asking if the client is taking any supplements is important because certain supplements can affect blood urea nitrogen (BUN) levels. For example, high protein supplements can increase BUN levels, while others might interact with medications or affect kidney function.
Choice B reason:
Inquiring about itching or hives is relevant for identifying potential allergic reactions or side effects from medications or supplements. However, it is not directly related to the BUN levels.
Choice C reason:
Dry skin can be a symptom of various conditions, including dehydration or kidney issues. While it is a useful question, it does not directly address the BUN levels.
Choice D reason:
Asking if the client has noticed the need to urinate less often is crucial for assessing kidney function. Reduced urine output can indicate kidney dysfunction, which can affect BUN levels.
Choice E reason:
Using salt substitutes is relevant because some contain potassium, which can affect kidney function and electrolyte balance. This question helps assess potential dietary influences on BUN levels.
Choice F reason:
Experiencing urgency to urinate can be a symptom of urinary tract issues or other conditions. While it is important to know, it is not directly related to the BUN levels.