A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

Urinary retention

Dilated pupils

Hypertension

Tachypnea

Answer and Explanation

The Correct Answer is A

Opioid medications can cause urinary retention by inhibiting the normal function of the bladder and reducing the urge to urinate. This can lead to incomplete emptying of the bladder and increased urine retention. Nurses should monitor clients receiving opioids for signs of urinary retention, such as decreased urine output, distended bladder, or discomfort in the lower abdomen.

Opioids generally cause pupil constriction (miosis) rather than dilation (mydriasis). Dilated pupils may indicate other drug use or neurological issues, but they are not a typical adverse effect of hydromorphone.

Hydromorphone is more likely to cause hypotension (low blood pressure) as an adverse effect rather than hypertension (high blood pressure).

Hydromorphone can cause respiratory depression, which is characterized by decreased respiratory rate and depth. Tachypnea (rapid breathing) is not a typical adverse effect of hydromorphone.

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Correct Answer is B

Explanation

To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I

It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.

Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.

Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.

A. Slurred speech B. Hypotension C. New onset of hearing loss D. Hyperthermia

Correct Answer is C

Explanation

When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify the new onset of hearing loss as an adverse eﬀect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can aﬀect hearing and balance¹.

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A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

Correct Answer is C

Explanation

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