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:
Assessing for hypoglycemia between meals is important, but it is not the most critical intervention. Insulin lispro is a rapid-acting insulin that peaks quickly, so timing meals with insulin administration is crucial to prevent hypoglycemia.
Choice B reason:
Checking blood glucose levels every six hours is a good practice for monitoring overall glucose control, but it does not address the immediate need to coordinate insulin administration with meals to prevent hypoglycemia.
Choice C reason:
Keeping an oral liquid or glucose source available is essential for treating hypoglycemia if it occurs. However, the primary focus should be on preventing hypoglycemia by ensuring that meals are timed appropriately with insulin administration.
Choice D reason:
Providing meals at the same time insulin is given is the most important intervention. Insulin lispro acts rapidly, and if meals are not timed correctly, there is a high risk of hypoglycemia. Ensuring that the client eats at the same time as the insulin injection helps maintain stable blood glucose levels.
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.