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?
Auscultate the client's bowel sounds. B. Observe for edema around the ankles.
Count the apical and radial pulses simultaneously.
Measure the client's capillary glucose level.
The Correct Answer is A
Hydromorphone is an opioid analgesic that can cause constipation as a side effect by slowing down gastrointestinal motility. Prolonged use of opioids, such as hydromorphone, increases the risk of developing opioid-induced constipation (OIC), which can lead to discomfort, bowel obstruction, and other complications if left untreated.
B. Edema is not typically associated with hydromorphone use, especially when administered for a short duration.
C. Hydromorphone administration is not typically associated with significant alterations in heart rate or rhythm, especially when administered at appropriate doses.
D. hydromorphone administration is not typically associated with alterations in blood glucose levels. Therefore, assessing capillary glucose levels may not be the most relevant assessment in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. For individuals with Huntington's disease, who may experience motor impairments and difficulties with coordination and balance, having someone escort them to the cafeteria could be the most practical and supportive approach.
A. Verbal directions may be a component of assistance but they may not be the most effective approach on their own.
B. Individuals with Huntington's disease may still have difficulties with executive function and orientation, which could limit their ability to effectively use a color coding system independently.
C. Providing a visual representation of the hospital layout using a map could be a helpful approach for a client with Huntington's disease. However, the cognitive and motor impairment present may hinder access even in the presence of a map.
Correct Answer is D
Explanation
D. Bismuth subsalicylate, a component of the regimen, has salicylate in its composition, which can lead to an increased risk of bleeding when taken with aspirin, a known blood thinner.
A. Loperamide is an antidiarrheal medication commonly used to treat diarrhea. It is not directly related to the treatment of Helicobacter pylori (H. pylori) infection.
B. Ipratropium is a bronchodilator medication used to treat conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It is not directly related to the treatment of H. pylori infection.
C. Famotidine is a histamine-2 (H2) receptor antagonist commonly used to reduce stomach acid production. It is not directly related to the treatment of H. pylori infection.
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