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 ["B","C","E"]
Explanation
Choice A Reason:
Providing a PRN NSAID for gum discomfort is not advisable in this situation. NSAIDs can increase the risk of bleeding, which is already a concern for a client on anticoagulants. Therefore, this action could exacerbate the client’s condition and should be avoided.
Choice B Reason:
Obtaining a soft bristle toothbrush for the client is a good practice to help minimize gum irritation and bleeding. Soft bristle toothbrushes are gentler on the gums and can help prevent further bleeding and discomfort, making this a suitable action for the nurse to implement.
Choice C Reason:
Reviewing the most recent coagulation lab values is crucial in this scenario. Coagulation tests, such as INR (International Normalized Ratio) or aPTT (activated partial thromboplastin time), can help determine if the anticoagulant dosage is appropriate or if adjustments are needed. This step is essential to ensure the client’s safety and effective management of their anticoagulation therapy.
Choice D Reason:
Completing a medication variance report is not immediately necessary unless there is evidence of a medication error. The priority should be to address the client’s symptoms and ensure their safety. While documentation is important, it should not take precedence over direct patient care in this situation.
Choice E Reason:
Reporting findings to the healthcare provider is essential. The development of bleeding and new bruises indicates a potential adverse reaction to the anticoagulant. The healthcare provider needs to be informed to assess the situation, possibly adjust the medication, and provide further instructions for managing the client’s condition.
Correct Answer is B
Explanation
Choice A Reason:
Photosensitivity is not a common side effect of gabapentin. While some medications can cause increased sensitivity to sunlight, gabapentin is not typically associated with this issue. Therefore, it is not a primary concern that needs to be reported to the healthcare provider.
Choice B Reason:
Rapid weight gain is a significant side effect that should be reported to the healthcare provider. Gabapentin can cause fluid retention and swelling, which may lead to rapid weight gain. This can be a sign of more serious underlying issues, such as heart or kidney problems, and requires prompt medical attention.
Choice C Reason:
Gastric irritation, such as nausea or upset stomach, can occur with gabapentin use but is generally not severe. While it can be uncomfortable, it is usually manageable with supportive care and does not typically require immediate reporting to a healthcare provider unless it becomes severe or persistent.
Choice D Reason:
Sexual dysfunction is not commonly associated with gabapentin. While some medications can affect sexual function, gabapentin’s side effects are more commonly related to the nervous system, such as dizziness, drowsiness, and coordination issues. Therefore, this is not a primary concern that needs to be reported.
