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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A Preventing esophageal reflux is essential in managing symptoms associated with a direct hiatal hernia. Nursing interventions may include promoting proper positioning (elevating the head of the bed), encouraging smaller, more frequent meals, avoiding trigger foods, and administering medications as prescribed to reduce acid reflux.

B Promoting intestinal peristalsis may be beneficial in certain gastrointestinal conditions, such as constipation but it is not directly related to the management of a direct hiatal hernia.

C Promoting effective swallowing is important for overall swallowing function and preventing aspiration in some cases, it may not directly address the symptoms or complications associated with a direct hiatal hernia.

D Maintaining intact oral mucosa is important for oral health and preventing complications such as oral mucositis, but it is not directly related to the management of a direct hiatal hernia.

A. Destruction of helper T-cells and CD4 cells. B. Increase in B-lymphocytes and IgM. C. Deficiency of cytotoxic T-cells. D. Proliferation of suppressor T-cells.

Correct Answer is A

Explanation

A. As HIV replicates within helper T-cells, it damages and destroys them, leading to a progressive decline in the number of CD4 cells in the body. This loss of helper T-cells weakens the immune system's ability to mount an effective response against infections

B. HIV infection does not typically lead to an increase in B-lymphocytes (B cells) or IgM antibodies.

C. While HIV infection can eventually lead to a deficiency in cytotoxic T-cells (CD8-positive T cells), particularly in advanced stages of the disease, the primary target of HIV is helper T-cells (CD4-positive T cells).

D. HIV infection does not result in the proliferation of suppressor T-cells (regulatory T cells).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Correct Answer is A

Explanation

The nurse is preparing a teaching plan for a group of clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of AIDS. The nurse should explain that HIV acts in which way to suppress the immune system?

Correct Answer is A

Explanation

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?