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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should identify that disposing of contaminated sheets in a linen bag demonstrates effective use of supplies.
Wearing an N95 mask when bathing a client with Clostridium difficile is important, but it is not related to effective use of supplies.
Wearing clean gloves when performing oral hygiene is standard practice for infection control and not specific to the use of supplies.
Empting the sharps container when it is full is also important, but it is not related to effective use of supplies.
Correct Answer is D
Explanation
A) Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B) Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C) Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
D) Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
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