A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

Respiratory rate.

Pain scale.

Blood pressure.

Level of consciousness.

Answer and Explanation

The Correct Answer is B

Rationale

A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.

B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.

C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.

D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.

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Correct Answer is ["A","D","G"]

Explanation

A. Allowing the client to find a comfortable position can help reduce anxiety and promote relaxation, which can be beneficial during an asthma exacerbation.
B. While the patient is currently receiving treatment with albuterol and oxygen, discussing aggressive respiratory treatment options may not be necessary at this moment unless the patient's condition deteriorates and requires escalation of care.
C. Deep tracheal suctioning is not indicated based on the current assessment findings unless there is a specific clinical indication such as excessive secretions or respiratory distress.
D. Identifying and discussing potential triggers is important for asthma management. This helps the client understand what factors might exacerbate their asthma and how to avoid them in the future.
E. Since the patient's oxygen saturation is still below target (91% on room air), weaning the supplemental oxygen is not appropriate at this time. The oxygen therapy should be continued as per the titration orders to maintain saturation above 94%.
F. Obtaining a sputum culture is not typically indicated in acute asthma exacerbations unless there is suspicion of a secondary infection or if the patient develops persistent fever and productive cough.
G. Continuously monitoring oxygen saturation is crucial to ensure it remains above 94%. This helps gauge the effectiveness of treatment and ensures the patient's respiratory status is stable.
H. Positive pressure ventilation is a more advanced intervention and is not indicated based on the current assessment findings. It would only be considered if the patient's condition worsens despite maximal medical therapy.

A. Leave the client's room and return later in the day. B. Refer client to the social worker for support therapy. C. Encourage client to implement relaxation techniques. D. Explain that insulin is a life-saving drug for the client.

Correct Answer is A

Explanation

Rationale

A. This allows the client time to process their emotions. A diagnosis with a chronic illness can be overwhelming.

B. Referring the client to a social worker for support therapy is a good idea for ongoing emotional support and counseling. However, at this moment, the client might need immediate assistance

C. While relaxation techniques can be helpful in managing stress and anxiety, they might not address the immediate need for insulin administration education.

D. Explaining the importance of insulin, is crucial, but it may not be effective if the client is not in a receptive state.

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A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Correct Answer is ["A","D","G"]

Explanation

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Correct Answer is A

Explanation

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A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?