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:
Glucagon is a hormone used to treat severe hypoglycemia (low blood sugar) in individuals with diabetes. Severe hypoglycemia can be life-threatening and requires immediate treatment to raise blood sugar levels. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. It is crucial for clients and their families to recognize the signs of severe hypoglycemia, such as confusion, unconsciousness, or seizures, and to administer glucagon promptly.
Choice B Reason:
Administering glucagon before meals to prevent hyperglycemia is incorrect. Glucagon is not used to prevent high blood sugar levels; it is specifically used to treat low blood sugar levels. Preventing hyperglycemia typically involves insulin administration and dietary management, not glucagon.
Choice C Reason:
While managing blood sugar levels during sick days is important, glucagon is not used for this purpose. Clients are usually advised to monitor their blood sugar levels more frequently and adjust their insulin doses as needed during illness. Glucagon is reserved for emergency situations involving severe hypoglycemia.
Choice D Reason:
Glucagon is not used to treat diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes that requires immediate medical attention and is treated with insulin, fluids, and electrolytes. Administering glucagon would not address the underlying issues of DKA and could potentially worsen the condition.
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.