The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Observe for edema around the ankles.

Count the apical and radial pulses simultaneously.

Measure the patient’s capillary glucose level.

Auscultate the patient’s bowel sounds.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

Observing for edema around the ankles is a relevant assessment, but it's not the most crucial one in this context. Edema can be a sign of fluid retention, which is a potential side effect of hydromorphone. However, it's not the most immediate or dangerous concern associated with prolonged hydromorphone use.

Rationale for Choice B:

Counting the apical and radial pulses simultaneously is a technique used to assess for pulse deficits, which can indicate heart rhythm irregularities. While hydromorphone can potentially cause cardiac effects, it's not the most common or primary concern with its use. Other assessments take priority.

Rationale for Choice C:

Measuring the patient's capillary glucose level is important for patients with diabetes or those at risk for hyperglycemia. However, there's no direct link between hydromorphone use and blood glucose levels. This assessment isn't the most relevant in this specific scenario.

Rationale for Choice D:

Auscultating the patient's bowel sounds is the most important assessment for a patient who has been receiving hydromorphone for four days. Here's why:

Hydromorphone is a potent opioid analgesic that can significantly slow down gastrointestinal motility. This can lead to constipation, which, if severe, can progress to ileus (a complete lack of bowel movement).

Ileus is a serious complication that can cause abdominal pain, bloating, nausea, vomiting, and even bowel obstruction or perforation if left untreated.

Auscultating bowel sounds helps assess the patient's bowel activity and detect early signs of constipation or ileus. Normal bowel sounds are typically heard every 5-15 seconds. Decreased or absent bowel sounds can indicate decreased bowel activity.

Early identification of constipation or ileus allows for prompt intervention, such as increasing fluid and fiber intake, administering laxatives or stool softeners, and potentially discontinuing or adjusting the hydromorphone dosage. This can prevent the development of more serious complications.

Therefore, auscultating the patient's bowel sounds is the most important assessment for the nurse to complete in this case, as it directly addresses the most significant potential complication associated with prolonged hydromorphone use.

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Correct Answer is B

Explanation

Choice A rationale:

Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.

While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.

Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.

Choice C rationale:

Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.

It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:

Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.

Choice B rationale:

Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.

Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.

Are comfortable for the patient and can be left in place for several days.

A. Colloidal oatmeal-based lotion. B. Topical corticosteroids. C. Topical analgesics. D. Topical antifungal.

Correct Answer is B

Explanation

Choice A rationale:

Colloidal oatmeal-based lotion: While colloidal oatmeal can soothe and moisturize dry, itchy skin, it does not have the anti- inflammatory properties necessary to effectively treat the underlying inflammation of psoriasis.

It may provide temporary relief of symptoms, but it won't address the root cause of the condition.

Choice B rationale:

Topical corticosteroids: These medications are the mainstay of treatment for psoriasis. They work by reducing inflammation and slowing the growth of skin cells.

Topical corticosteroids come in a variety of strengths and formulations, including creams, ointments, gels, lotions, and sprays. The choice of formulation will depend on the severity of the psoriasis, the location of the lesions, and the patient's preferences. Choice C rationale:

Topical analgesics: Topical analgesics, such as lidocaine or benzocaine, can help to relieve pain and itching associated with psoriasis.

However, they do not address the underlying inflammation and are not a long-term solution for managing the condition. They are typically used as adjunctive therapy, in conjunction with other psoriasis treatments.

Choice D rationale:

Topical antifungals: Topical antifungal medications are used to treat fungal infections, such as ringworm and athlete's foot. They are not effective in treating psoriasis, which is an autoimmune condition, not a fungal infection.

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The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

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