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 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.
Correct Answer is D
Explanation
Choice A reason:
Requesting a prescription to change the route of administration and use the available heparin is not appropriate. Low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are not interchangeable on a unit-for-unit basis. They have different pharmacokinetics and dosing requirements. Changing the route without proper guidance can lead to incorrect dosing and potential complications.
Choice B reason:
Calculating and administering the equivalent dose of the available low molecular weight heparin is incorrect. LMWH and UFH have different dosing protocols and are not directly interchangeable. Administering LMWH instead of UFH without proper conversion and guidance can result in inappropriate anticoagulation.
Choice C reason:
Diluting the available heparin in 250 ml of normal saline solution prior to IV administration is not appropriate. The prescription specifies heparin 5000 units IV STAT, which indicates an immediate need for intravenous administration. Diluting and administering it in this manner does not align with the urgency of the order.
Choice D reason:
Advising the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately is the correct action. This ensures that the client receives the prescribed medication in the correct form and dosage as ordered by the healthcare provider. It is crucial to follow the specific instructions for heparin administration to ensure patient safety and effective anticoagulation.