The nurse reviews the laboratory values. What question(s) can the nurse ask the client based on the laboratory results? Select all that apply.

Choice A reason:

Counting the apical and radial pulses simultaneously can help detect pulse deficits, which may indicate cardiac issues. However, this is not the most critical assessment for a client receiving hydromorphone.

Choice B reason:

Observing for edema around the ankles is important for assessing fluid retention and potential heart failure. While relevant, it is not the primary concern for a client on hydromorphone.

Choice C reason:

Auscultating the client’s bowel sounds is crucial because hydromorphone, like other opioids, can cause constipation and potentially lead to paralytic ileus, a serious condition where the intestines stop moving food through. Monitoring bowel sounds helps detect early signs of this complication.

Choice D reason:

Measuring the client’s capillary glucose level is important for diabetic patients or those at risk of hyperglycemia. However, it is not directly related to the administration of hydromorphone.

Choice A Reason:

Checking for the correct placement of the patch behind the client’s ear is important to ensure proper administration of the medication. However, this action does not address the client’s concern about pain relief. Scopolamine is used to prevent nausea and vomiting, not to manage pain. Therefore, while correct placement is necessary, it does not explain why the client is still experiencing pain.

Choice B Reason:

Offering to apply a new transdermal patch to relieve the pain is not appropriate because scopolamine is not intended for pain relief. Applying a new patch would not address the client’s pain and could lead to unnecessary medication use. The nurse should clarify the purpose of the medication instead.

Choice C Reason:

Explaining that the medication is not given to prevent pain is the correct action. Scopolamine is an anticholinergic medication used to prevent nausea and vomiting associated with motion sickness and recovery from anesthesia. It is not an analgesic and does not provide pain relief. The nurse should inform the client about the intended use of the medication and address pain management separately.

Choice D Reason:

Advising the client that the effects of the medication have worn off is incorrect. Scopolamine patches are designed to release medication over a period of up to 72 hours. The effects would not wear off within a few hours. This statement does not address the client’s misunderstanding about the purpose of the medication.