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:
Depression screening is important for overall health and well-being, especially in weight management programs where mental health can significantly impact outcomes. However, it is not the primary measure for determining the effectiveness of orlistat. Orlistat works by inhibiting the absorption of fats from the diet, leading to weight loss. Therefore, while mental health monitoring is crucial, it does not directly measure the medication’s effectiveness.
Choice B Reason:
Daily calorie count is a useful tool in weight management programs to ensure that clients are adhering to a calorie-restricted diet. However, it is not a direct measure of the effectiveness of orlistat. While calorie counting can help manage weight, the primary goal of orlistat is to reduce fat absorption, which is better reflected in changes in body weight and BMI.
Choice C Reason:
Body mass index (BMI) is a key indicator of weight management and is directly related to the effectiveness of orlistat. BMI is calculated based on height and weight, providing a clear measure of changes in body weight over time. Monitoring BMI helps determine if the client is losing weight as expected, making it the most appropriate assessment for evaluating the effectiveness of orlistat.
Choice D Reason:
Serum protein levels are important for assessing nutritional status and overall health. However, they do not directly measure the effectiveness of orlistat in a weight management program. Orlistat’s primary function is to reduce fat absorption, and its effectiveness is better assessed through changes in body weight and BMI rather than serum protein levels.
Correct Answer is A
Explanation
Choice A Reason:
Sodium polystyrene sulfonate is used to treat hyperkalemia (high potassium levels) by exchanging sodium ions for potassium ions in the intestines, which are then excreted in the stool. A serum potassium level of 3.8 mEq/L is within the normal range (3.5 to 5 mEq/L), indicating that the medication has effectively reduced the potassium level to a safe range. Monitoring potassium levels is crucial in clients with AKI to prevent complications such as cardiac arrhythmias.
Choice B Reason:
A hemoglobin level of 13.3 g/dL is slightly below the normal range for adults (14 to 18 g/dL for males and 12 to 16 g/dL for females). While it is important to monitor hemoglobin levels, this value does not directly indicate the effectiveness of sodium polystyrene sulfonate, which is specifically used to manage potassium levels.
Choice C Reason:
A serum ammonia level of 30 µg/dL is within the normal range (10 to 80 µg/dL). However, this value does not reflect the effectiveness of sodium polystyrene sulfonate, as the medication is not used to manage ammonia levels. Ammonia levels are more relevant in conditions affecting liver function, such as hepatic encephalopathy.
Choice D Reason:
A serum glucose level of 100 mg/dL is within the normal range (74 to 106 mg/dL). While it is important to monitor glucose levels, this value does not indicate the effectiveness of sodium polystyrene sulfonate. The medication’s primary function is to reduce potassium levels, not to manage glucose levels.