When managing a patient with severe pain using hydromorphone, which of the following interventions should the nurse perform to prevent complications? (Select all that apply.)

Monitor respiratory rate regularly

Assess for signs of constipation

Encourage increased fluid intake

Administer with a high-calorie meal

Limit activity to prevent dizziness

Avoid combining with NSAIDs

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Monitoring respiratory rate is essential when administering hydromorphone, a potent opioid. Respiratory depression is a serious adverse effect, especially in opioid-naïve patients or those receiving high doses. Early detection of hypoventilation can prevent life-threatening complications.

Choice B reason: Constipation is a common side effect of opioids due to decreased gastrointestinal motility. Regular assessment and proactive management with stool softeners or laxatives are necessary to prevent discomfort and complications such as fecal impaction.

Choice C reason: Encouraging fluid intake helps mitigate opioid-induced constipation and supports overall hydration, which is important for maintaining renal function and preventing urinary retention.

Choice D reason: Hydromorphone does not require administration with a high-calorie meal. Unlike some medications that cause gastric irritation, opioids are not food-dependent. This intervention does not prevent complications and may be misleading.

Choice E reason: Limiting activity is not recommended unless the patient experiences severe dizziness or orthostatic hypotension. Encouraging safe mobility helps prevent complications such as deep vein thrombosis and promotes recovery.

Choice F reason: NSAIDs can be used cautiously with opioids for multimodal pain management unless contraindicated. They do not interact directly with hydromorphone to cause complications, although they should be used carefully in patients with renal impairment or bleeding risk.

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Correct Answer is D

Explanation

Choice A reason: Wound dehiscence refers to the separation of surgical incision edges and is typically associated with visible changes at the wound site, such as drainage or protrusion of internal contents. It does not cause absent bowel sounds or distention.

Choice B reason: Cholecystitis is inflammation of the gallbladder, often presenting with right upper quadrant pain, fever, and nausea. It does not typically cause generalized abdominal distention or absence of bowel sounds.

Choice C reason: Ulcerative colitis is a chronic inflammatory bowel disease affecting the colon. It presents with diarrhea, rectal bleeding, and abdominal cramping, but not with absent bowel sounds or postoperative ileus.

Choice D reason: Paralytic ileus is a temporary cessation of bowel motility, often occurring after abdominal surgery. It presents with absent bowel sounds, abdominal distention, and failure to pass flatus or stool. This is the most likely diagnosis in a postoperative patient with these findings.

A. Sit the client upright. B. Stop the TPN infusion. C. Prepare to add insulin to the TPN infusion. D. Turn the client on his left side.

Correct Answer is B

Explanation

Choice A reason: Sitting the client upright may help with respiratory symptoms if fluid overload or dyspnea occurs, but it does not address the underlying issue of rapid TPN infusion. It is a supportive measure, not a corrective action.

Choice B reason: Stopping the TPN infusion is the immediate and appropriate response to prevent complications such as hyperglycemia, fluid overload, and electrolyte imbalance. TPN must be administered at a controlled rate to avoid metabolic disturbances. Halting the infusion allows the nurse to reassess and notify the provider for further instructions.

Choice C reason: Adding insulin to the TPN solution is a preemptive measure used when hyperglycemia is anticipated or present. It is not a corrective action for rapid infusion and should only be done under provider orders with proper monitoring.

Choice D reason: Turning the client on the left side is a maneuver used in certain emergency situations, such as air embolism, but it is not relevant to TPN infusion rate issues. It does not mitigate the risks associated with rapid nutrient delivery.

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When managing a patient with severe pain using hydromorphone, which of the following interventions should the nurse perform to prevent complications? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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