A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

Respiratory rate.

Pain scale.

Blood pressure.

Level of consciousness.

Answer and Explanation

The Correct Answer is B

Rationale

A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.

B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.

C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.

D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.

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Correct Answer is D

Explanation

Rationale

A. Herpes simplex virus type II (HSV-II) primarily spreads through direct contact with the lesions and is not airborne. Airborne precautions and negative airflow rooms are not necessary for this condition.

B. Scarlet fever is caused by Group A Streptococcus bacteria and typically spreads through respiratory droplets. However, scarlet fever itself does not require airborne precautions. If complicated with pneumonia, respiratory droplets could potentially spread the infection, but specific airborne precautions are generally not required unless there are other pathogens involved that require it.

C. Scabies is caused by the Sarcoptes scabiei mite and spreads through direct skin-to-skin contact. It does not require airborne precautions or negative airflow rooms.

D. Apositive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) suggest tuberculosis (TB) infection. TB is spread through airborne droplets (e.g., coughing, sneezing), and therefore, requires airborne precautions including negative airflow rooms to prevent transmission to others.A

A. Reassure the client that the nurse will return after all vital signs are taken. B. Tell the client that he must release the nurse's hand. C. Pull up a chair and sit beside the client's bed. D. Allow the client to hold the nurse's hand until the vital signs can be completed.

Correct Answer is D

Explanation

Rationale

A. This response acknowledges the client's need for reassurance and informs them of the nurse's plan. However, it may not address the immediate need for comfort and connection expressed by the client.

B. This response may come across as dismissive or insensitive to the client's emotional and psychological needs. It could potentially increase anxiety or distress in an already vulnerable client.

C. Sitting beside the client demonstrates empathy and provides physical presence, which can be reassuring and comforting. However, it is not practical as the nurse has other duties to attend to.

D. It addresses the patient's immediate emotional needs without compromising the nurse's ability to perform their duties.

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A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

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Naxlex Comprehensive Predictor Exams

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is D

Explanation

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

Correct Answer is D

Explanation

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