A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus.
10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

This question addresses the monitoring requirements for patients receiving potent opioid analgesics. It requires applying knowledge of opioid-induced respiratory depression, which is the most dangerous potential adverse effect, requiring constant vigilance to ensure patient safety and prevent hypoxic events during the postoperative recovery period.

Choice A rationale

While opioids can cause hypotension due to peripheral vasodilation, it is not as acutely life-threatening as respiratory depression. Blood pressure monitoring is important but secondary to the immediate, time-critical need to ensure the patient maintains a safe and effective rate of breathing.

Choice B rationale

Opioids do not typically cause direct changes to body temperature. While temperature monitoring is part of standard postoperative care to detect infection or other complications, it is not the primary vital sign concern when administering a dose of hydromorphone.

Choice C rationale

Hydromorphone is a powerful opioid that acts on central nervous system receptors to suppress the respiratory drive. Shallow respirations or a low respiratory rate are the most serious adverse effects, requiring immediate assessment to prevent respiratory arrest and significant patient harm.

Choice D rationale

Opioids can cause bradycardia, but this is generally managed effectively unless the patient is hemodynamically unstable. Heart rate is a vital parameter to monitor, but it is not the primary physiological concern following the administration of a potent opioid medication..

This question evaluates the technique for safe ophthalmic medication administration. It requires applying the principles of aseptic technique and proper anatomical placement of drops to ensure maximum therapeutic drug absorption into the eye while minimizing systemic absorption and preventing potential contamination of the medication bottle.

Choice A rationale

Protecting the distal portion of the eyedropper with clean technique is insufficient for preventing contamination. The nurse must use strict sterile technique, ensuring the tip never touches the patient’s eye, eyelid, or any surface to maintain the sterility of the medication.

Choice B rationale

The conjunctival sac is the correct anatomical site for instilling eye drops. Placing the medication into the lower conjunctival sac ensures proper distribution over the surface of the eye, facilitating therapeutic drug absorption for the effective management of glaucoma in the patient.

Choice C rationale

Cleaning the eye must always be done from the inner canthus to the outer canthus. Wiping from outer to inner canthus risks dragging contaminants or debris into the lacrimal duct, increasing the risk of infection or irritation of the ocular tissues.

Choice D rationale

Applying pressure to the bridge of the nose is incorrect. The nurse should apply pressure to the nasolacrimal duct (inner canthus) after administration to minimize systemic absorption of the medication, preventing unwanted cardiovascular or respiratory side effects from the drug entering the bloodstream.