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:
Determining the presence of abdominal pain is crucial because long-term use of ibuprofen can lead to gastrointestinal issues, including ulcers and bleeding. Abdominal pain can be an early sign of these complications, and prompt identification is essential to prevent more severe outcomes. Monitoring for gastrointestinal symptoms is a key aspect of managing patients on chronic NSAID therapy.
Choice B Reason:
While palpating the volume of pedal pulses is important for assessing peripheral circulation, it is not directly related to the potential side effects of long-term ibuprofen use. This assessment is more relevant for conditions affecting blood flow, such as peripheral artery disease, rather than for monitoring ibuprofen-related complications.
Choice C Reason:
Evaluating ongoing sleep patterns can provide valuable information about the client’s overall well-being and pain management. However, it is not the most critical assessment in the context of long-term ibuprofen use. Sleep disturbances may be related to chronic pain but are not directly indicative of ibuprofen’s adverse effects.
Choice D Reason:
Assessing back pain using a numeric scale is essential for evaluating the effectiveness of pain management strategies. However, it does not address the potential adverse effects of long-term ibuprofen use. While pain assessment is important, monitoring for signs of gastrointestinal complications takes precedence in this scenario.
Correct Answer is D
Explanation
Choice A Reason:
While keeping skin and eyes covered to protect from sun injury is generally good advice, it is not specifically related to the use of oxybutynin. Oxybutynin can reduce sweating, which increases the risk of overheating and dehydration, especially during physical activities like running a half-marathon. Therefore, this advice, while useful, is not the most critical in this context.
Choice B Reason:
Avoiding crowds to help prevent acquiring infections is important for overall health, especially for individuals with compromised immune systems. However, this advice is not directly related to the use of oxybutynin or the specific risks associated with its use during physical exercise. The primary concern with oxybutynin is its effect on sweating and body temperature regulation.
Choice C Reason:
Wearing padding to protect from bruising if a fall occurs is a precaution that might be relevant for individuals at risk of falls or injuries. However, this advice does not address the specific risks associated with oxybutynin use during physical exercise. The main concern is the potential for overheating and dehydration due to reduced sweating.
Choice D Reason:
Taking measures to avoid dehydration and overheating is the most critical instruction for a client using oxybutynin while training for a half-marathon. Oxybutynin can decrease sweating, making it harder for the body to cool down during exercise. This can lead to heat stroke or severe dehydration. The nurse should emphasize the importance of staying hydrated, taking breaks, and avoiding excessive heat to prevent these serious complications.
