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:
Initiating cardiopulmonary resuscitation (CPR) is a critical action when a patient is in cardiac arrest or not breathing. However, in this scenario, the client is experiencing severe respiratory depression due to opioid overdose, and the first line of treatment is to administer naloxone. If the client does not respond to naloxone, then CPR may be necessary, but the immediate step is to address the opioid toxicity.
Choice B Reason:
Preparing to assist with chest tube insertion is not relevant in this context. Chest tubes are typically used to treat conditions like pneumothorax or pleural effusion. The client’s symptoms are due to opioid-induced respiratory depression, which requires naloxone administration rather than chest tube insertion.
Choice C Reason:
Administering a second dose of naloxone is the appropriate action. Naloxone is an opioid antagonist that reverses the effects of opioid overdose, including respiratory depression. Given the client’s critically low respiratory rate and oxygen saturation, a second dose of naloxone is necessary to counteract the opioid effects and restore normal breathing.
Choice D Reason:
Determining the Glasgow Coma Scale (GCS) score is useful for assessing the level of consciousness, but it does not directly address the immediate need to reverse the opioid-induced respiratory depression. The priority is to administer naloxone to improve the client’s respiratory status. Once the client is stabilized, further assessments, including the GCS score, can be conducted.
Correct Answer is A
Explanation
Choice A reason:
Measuring the client’s blood pressure is the most direct and effective way to assess the effectiveness of amlodipine. Amlodipine is a calcium channel blocker primarily used to treat hypertension and angina. Its main action is to relax the blood vessels, which lowers blood pressure. Regular monitoring of blood pressure helps determine if the medication is achieving its intended effect.
Choice B reason:
Monitoring the client’s serum electrolytes is important for overall health, but it is not the primary method to assess the effectiveness of amlodipine. Amlodipine does not significantly affect serum electrolyte levels, so this action would not provide specific information about the drug’s effectiveness.
Choice C reason:
Noting the client’s serum calcium levels is not necessary for assessing the effectiveness of amlodipine. Amlodipine does not alter serum calcium levels, as its mechanism of action involves blocking calcium channels in the blood vessels, not affecting calcium levels in the blood.
Choice D reason:
Reviewing the client’s intake and output can be useful for monitoring fluid balance and kidney function, but it is not the primary method to assess the effectiveness of amlodipine. This action does not directly measure the drug’s impact on blood pressure.