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:
Avoiding taking the medication on an empty stomach is important to reduce gastrointestinal upset. Lithium can cause stomach irritation, and taking it with food can help mitigate this side effect. However, while this is good advice, it is not the most critical instruction to emphasize.
Choice B Reason:
Reporting fluctuations in weight to the healthcare provider is essential because significant weight changes can indicate potential side effects or complications from lithium therapy. Weight gain or loss can be a sign of thyroid dysfunction or other metabolic issues. While important, it is not the primary instruction to emphasize.
Choice C Reason:
Maintaining a fluid intake of 1500 to 2000 mL per day is crucial for clients taking lithium. Lithium levels in the blood can be affected by fluid balance, and dehydration can lead to lithium toxicity. Ensuring adequate hydration helps maintain stable lithium levels and reduces the risk of toxicity. This is the most critical instruction to emphasize to ensure the client’s safety and effective management of their condition.
Choice D Reason:
Keeping medication fliers for frequent review and reference is helpful for understanding the medication and its potential side effects. However, it is not the most critical instruction. The primary focus should be on maintaining proper hydration to prevent lithium toxicity.
Correct Answer is A
Explanation
Choice A reason:
Administering iodine one hour before PTU is recommended because iodine can help reduce the thyroid hormone levels more effectively when given before PTU. This sequence ensures that the iodine is absorbed and utilized by the thyroid gland before PTU inhibits the synthesis of new thyroid hormones.
Choice B reason:
Scheduling both medications at bedtime is not appropriate. PTU and iodine solutions should be administered at specific times to maximize their effectiveness. PTU is typically given in divided doses throughout the day, while iodine solutions are often given before meals.
Choice C reason:
Administering both drugs together with a meal is incorrect. PTU should be taken on an empty stomach to ensure proper absorption, and iodine solutions are usually given before meals.
Choice D reason:
Giving a parenteral dose once every 24 hours is not applicable for these medications. PTU is administered orally in divided doses, and iodine solutions are also given orally.
