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 C
Explanation
Choice A reason:
While some herbal preparations may have a placebo effect, echinacea has been shown to have active properties that can aid in the treatment of infections. Echinacea contains compounds that boost the immune system and have anti-inflammatory effects, which can help in the healing process of canker sores.
Choice B reason:
Topical echinacea is not typically used to soothe burns, and there is no evidence to suggest it causes damage to the skin. In fact, echinacea is often used in topical preparations to treat skin conditions due to its anti-inflammatory and antimicrobial properties.
Choice C reason:
Echinacea has been found to be useful in treating some infections, including canker sores. Its immune-boosting and wound-healing properties can help reduce the duration and severity of canker sores. This makes it a beneficial herbal remedy for such conditions.
Choice D reason:
While echinacea is generally considered safe and harmless, it is not accurate to say it is not beneficial in treating skin infections. Echinacea has been used traditionally to treat various skin conditions and infections due to its antimicrobial and anti-inflammatory effects.
Correct Answer is B
Explanation
Choice A Reason:
A digoxin level of 1.1 ng/mL is within the therapeutic range of 0.8 to 2.6 ng/mL. Therefore, this value does not require immediate reporting to the healthcare provider. Monitoring digoxin levels is important to avoid toxicity, but this specific level is considered safe.
Choice B Reason:
A potassium level of 3.2 mEq/L is below the normal range of 3.5 to 5.0 mEq/L. Hypokalemia (low potassium levels) can increase the risk of digoxin toxicity, as digoxin and potassium compete for the same binding sites on the Na+/K+ ATPase pump. Low potassium levels can enhance the effects of digoxin, leading to potentially dangerous cardiac arrhythmias. Therefore, this value should be reported immediately.
Choice C Reason:
A creatinine level of 0.8 mg/dL is within the normal range of 0.5 to 1.1 mg/dL. This value indicates normal kidney function, which is important for the excretion of digoxin. Therefore, this value does not require immediate reporting.
Choice D Reason:
A sodium level of 135 mEq/L is just below the normal range of 136 to 145 mEq/L. While slightly low, this value is not critically abnormal and does not pose an immediate threat. It should be monitored, but it does not require urgent reporting to the healthcare provider.