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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["18"]
Explanation
(Desired Dose * Volume of IV Bag) / (Concentration of Drug in IV Bag * Time) = Infusion Rate.
For the given prescription, the calculation would be: (900 units/hr * 500 mL) / (25,000 units) = 18 mL/hr.
Therefore, the nurse should program the infusion pump to deliver 18 mL/hr.
Correct Answer is ["A","B","D","G","H"]
Explanation
A. Assessing temperature is important to monitor for any signs of infection or inflammation, which could exacerbate the asthma condition or indicate a concurrent illness.
B. Evaluating breath sounds helps determine the effectiveness of the albuterol treatment in relieving bronchospasm. Clearer breath sounds suggest improved air entry and reduced wheezing.
C. While CBC can provide valuable information, it is not typically immediately necessary after an albuterol treatment unless there are specific concerns about infection or other systemic issues.
D. Monitoring the heart rate is crucial as albuterol can cause tachycardia (elevated heart rate) as a side effect. It's important to ensure that the heart rate does not become excessively elevated, which may indicate a need to adjust treatment or monitor more closely.
E. Peak inspiratory flow is less commonly used in asthma management compared to peak expiratory flow. It's the maximum flow rate during inhalation and is not typically assessed routinely in the immediate post-treatment period.
F. Assessing serum sodium is not directly related to monitoring asthma exacerbation or response to bronchodilator therapy.
G. PEF measures the maximum speed at which a person can exhale air after a deep breath. It is a direct indicator of lung function and the severity of airway obstruction in asthma. Assessing PEF post-albuterol treatment helps gauge how well the airways have responded to the bronchodilator therapy.
H. Checking oxygen saturation ensures that the patient's oxygen levels have improved following the administration of albuterol. The goal is to maintain oxygen saturation above 94%, as per the treatment plan.
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