To manage postoperative pain, the physician prescribed hydromorphone.
Which vital sign should be the nurse's primary concern?
Blood pressure.
Temperature.
Respirations.
Heart rate.
The Correct Answer is C
This question addresses the monitoring requirements for patients receiving potent opioid analgesics. It requires applying knowledge of opioid-induced respiratory depression, which is the most dangerous potential adverse effect, requiring constant vigilance to ensure patient safety and prevent hypoxic events during the postoperative recovery period.
Choice A rationale
While opioids can cause hypotension due to peripheral vasodilation, it is not as acutely life-threatening as respiratory depression. Blood pressure monitoring is important but secondary to the immediate, time-critical need to ensure the patient maintains a safe and effective rate of breathing.
Choice B rationale
Opioids do not typically cause direct changes to body temperature. While temperature monitoring is part of standard postoperative care to detect infection or other complications, it is not the primary vital sign concern when administering a dose of hydromorphone.
Choice C rationale
Hydromorphone is a powerful opioid that acts on central nervous system receptors to suppress the respiratory drive. Shallow respirations or a low respiratory rate are the most serious adverse effects, requiring immediate assessment to prevent respiratory arrest and significant patient harm.
Choice D rationale
Opioids can cause bradycardia, but this is generally managed effectively unless the patient is hemodynamically unstable. Heart rate is a vital parameter to monitor, but it is not the primary physiological concern following the administration of a potent opioid medication..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["750"]
Explanation
Step 1 is convert weight in lbs to kg: 55 lbs ÷ 2.2 lbs/kg = 25 kg.
Step 2 is calculate the dose: 30 mcg/kg × 25 kg = 750 mcg. Final calculated answer is 750 mcg.
Correct Answer is D
Explanation
This question tests for knowledge of the adverse effects of prolonged topical decongestant use. It requires recognizing the pathophysiology of rebound congestion, which occurs when the nasal mucosa becomes dependent on exogenous adrenergic stimulation to maintain vasoconstriction, leading to severe chronic swelling upon cessation.
Choice A rationale
Nasal decongestants like phenylephrine are sympathomimetic agents that act locally on alpha-adrenergic receptors. They are not associated with systemic cholinergic inhibition that would cause constipation, which is a typical side effect of agents like anticholinergics or opioid medications.
Choice B rationale
Phenylephrine does not stimulate the production of respiratory secretions. It works through vasoconstriction of the nasal blood vessels to reduce mucosal edema, and it does not have a mechanism that would induce the production of sputum or productive cough.
Choice C rationale
Phenylephrine is a systemic or topical sympathomimetic stimulant. It does not possess sedative properties; in fact, patients may experience nervousness, insomnia, or increased heart rate due to its stimulatory effects on the sympathetic nervous system and its receptors.
Choice D rationale
Long-term use of nasal decongestants leads to rhinitis medicamentosa, or rebound congestion. The nasal blood vessels lose their ability to constrict normally after prolonged stimulation, resulting in increased swelling and severe congestion when the medication is discontinued by the patient.
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