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 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:
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.