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 C
Explanation
Choice A Reason:
Bronchitis is a condition that affects the respiratory system, and while it is important to monitor, it is not a primary concern when administering phenylephrine. Phenylephrine is a decongestant that works by narrowing the blood vessels in the nasal passages, which can help relieve congestion but does not directly impact bronchitis.
Choice B Reason:
Diarrhea is a gastrointestinal condition that, while uncomfortable, does not significantly interact with phenylephrine. It is important to manage and monitor, but it does not pose a direct risk when taking phenylephrine.
Choice C Reason:
Hypertension is a significant concern when administering phenylephrine. Phenylephrine can increase blood pressure by causing vasoconstriction. For clients with hypertension, this can exacerbate their condition and lead to serious cardiovascular complications. Therefore, it is crucial to report this condition to the healthcare provider before administering the medication.
Choice D Reason:
Edema, or swelling, can be a symptom of various underlying conditions, including heart failure or kidney issues. While it is important to monitor, it is not as directly impacted by phenylephrine as hypertension. However, any underlying condition causing edema should be considered when administering medications.
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.
