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 A

Explanation

The correct answer is: a. Clean the stoma using an inward to outward circular motion.

Title: Choice A reason: Cleaning the stoma with an inward to outward circular motion is a recommended practice to prevent infection and ensure that any debris or secretions are cleared away from the tracheostomy site. This method helps to minimize the risk of introducing pathogens directly into the stoma and is considered a best practice in tracheostomy care.

Title: Choice B reason: Cleansing the inner cannula with isopropyl alcohol is not recommended because it can cause irritation to the tracheal mucosa. Instead, sterile saline is typically used for cleaning the inner cannula to avoid any potential damage to the tracheal tissues and to maintain a safe and comfortable environment for the patient.

Title: Choice C reason: Ensuring at least three finger widths of space under tracheostomy ties is not the standard practice. The recommended space is to allow one to two finger widths under the tracheostomy ties to ensure they are secure but not too tight, which could lead to skin breakdown or discomfort for the patient.

Title: Choice D reason: Preparing sterile supplies should be done before removing the inner cannula, not after. This is to ensure that all necessary supplies are ready to use immediately after the inner cannula is removed, minimizing the time the stoma is open and reducing the risk of infection.

A. "I should take a zinc supplement while taking this medication." B. "This medication will dilate my eyes." C. "I should check my heart rate while taking this medication." D. "This medication will darken the color of my eyes."

Correct Answer is C

Explanation

Timolol is a beta-blocker medication that is commonly prescribed for the treatment of glaucoma. It works by reducing the production of aqueous humor in the eye, thereby decreasing intraocular pressure. However, timolol can also be systemically absorbed, which may lead to cardiovascular side effects.

Checking the heart rate while taking timolol is important because beta-blockers can potentially lower heart rate and blood pressure. It is essential to monitor for any changes in heart rate or any other cardiovascular symptoms while using timolol eye drops.

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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 preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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