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 A
Explanation
A. Pyridostigmine is a cholinergic medication that can affect bladder function, and difficulty with urination could indicate a bladder obstruction, which is a contraindication for this medication.
B. Trouble sleeping or insomnia is not typically associated with pyridostigmine use.
C. Unexplained weight loss is not a common side effect of pyridostigmine.
D. Administering pyridostigmine with food or shortly after a meal may help minimize gastrointestinal side effects such as nausea and abdominal discomfort. This however, is not of immediate concern when administering pyridostigmine.
Correct Answer is D
Explanation
D. One of the potential side effects of albuterol is tachycardia (irregular rapid heart beat) due to its stimulatory effects on beta-adrenergic receptors in the heart.
A. While tremors can be distressing for the client, they are generally benign and do not typically require immediate intervention by the nurse.
B. While uncomfortable, throat irritation is generally mild and self-limiting and does not typically require immediate intervention by the nurse.
C. Increased anxiety alone does not typically warrant immediate intervention by the nurse unless it is severe or accompanied by other concerning symptoms.
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