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 B
Explanation
B. Obstruction of bile flow leads to accumulation of bilirubin, a pigment produced by the breakdown of red blood cells, in the bloodstream and causes jaundice (yellowing of the sclera). Yellow sclera is a concerning sign that should be reported promptly to the healthcare provider as it indicates potential bile duct obstruction and impaired liver function
A. Amber urine refers to urine that is dark yellow, often indicating concentrated urine due to dehydration or certain medications. While amber urine may be noted in various conditions, it is not specifically indicative of a complication related to cholelithiasis.
C. While flatulence may be uncomfortable for the client, it is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
D. belching may be uncomfortable for the client but is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
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.
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