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 A
Explanation
Choice A Reason:
St. John’s Wort is known to significantly decrease the blood concentrations of cyclosporine, a critical immunosuppressant used to prevent organ rejection in transplant patients. This herb induces the activity of cytochrome P450 enzymes, particularly CYP3A4, which increases the metabolism of cyclosporine, leading to lower plasma levels and a higher risk of graft rejection. This interaction is highly significant and requires immediate attention to adjust the client’s medication regimen and prevent further complications.
Choice B Reason:
While it is true that St. John’s Wort is commonly used to treat depression, this information is not as significant in the context of graft rejection. The primary concern is the herb’s interaction with cyclosporine, which directly impacts the effectiveness of the immunosuppressive therapy. Understanding the reason for using the herb is important, but it does not address the immediate risk of graft rejection.
Choice C Reason:
There is no substantial evidence to suggest that ingestion of St. John’s Wort reduces sodium intake. This statement does not relate to the herb’s interaction with cyclosporine or its impact on graft rejection. Therefore, it is not a significant concern in this scenario.
Choice D Reason:
Adding St. John’s Wort does not decrease the need for corticosteroids. In fact, the herb’s interaction with cyclosporine can lead to inadequate immunosuppression, potentially increasing the need for additional medications to manage graft rejection. This statement is incorrect and does not address the critical issue of cyclosporine metabolism.
Correct Answer is B
Explanation
Choice A Reason:
While monitoring temperature is important for overall health assessment, it is not the most critical vital sign to check first in the context of opioid-induced lethargy. Opioids primarily affect the respiratory system, and respiratory depression is a significant risk. Therefore, temperature is not the priority in this scenario.
Choice B Reason:
Respiratory rate is the most critical vital sign to check first. Opioids can cause respiratory depression, which can be life-threatening. A decreased respiratory rate is a key indicator of opioid overdose or severe side effects. Monitoring the respiratory rate allows the nurse to assess the severity of the respiratory depression and take immediate action if necessary.
Choice C Reason:
Pulse rate is also an important vital sign, but it is secondary to respiratory rate in this context. While opioids can affect heart rate, the immediate concern with opioid-induced lethargy is respiratory depression. Therefore, checking the respiratory rate takes precedence over the pulse rate.
Choice D Reason:
Blood pressure is another vital sign that should be monitored, but it is not the first priority in this situation. Opioids can cause hypotension, but the primary and most immediate concern is respiratory depression. Therefore, the respiratory rate should be assessed first to ensure the client’s airway and breathing are adequate.