The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?
Auscultate the client's bowel sounds. B. Observe for edema around the ankles.
Count the apical and radial pulses simultaneously.
Measure the client's capillary glucose level.
The Correct Answer is A
Hydromorphone is an opioid analgesic that can cause constipation as a side effect by slowing down gastrointestinal motility. Prolonged use of opioids, such as hydromorphone, increases the risk of developing opioid-induced constipation (OIC), which can lead to discomfort, bowel obstruction, and other complications if left untreated.
B. Edema is not typically associated with hydromorphone use, especially when administered for a short duration.
C. Hydromorphone administration is not typically associated with significant alterations in heart rate or rhythm, especially when administered at appropriate doses.
D. hydromorphone administration is not typically associated with alterations in blood glucose levels. Therefore, assessing capillary glucose levels may not be the most relevant assessment in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Sputum culture is the gold standard diagnostic test for confirming the diagnosis of tuberculosis. It involves culturing the bacteria from sputum samples to identify the presence of Mycobacterium tuberculosis, the causative organism of TB.
A. The Hemoccult test is used to detect occult (hidden) blood in stool samples, not sputum.
B. Chest x-ray or CT imaging is commonly used in the diagnosis of tuberculosis. However, imaging findings alone are not sufficient to confirm the diagnosis of TB.
C. The PPD skin test is a screening test for tuberculosis infection. A positive PPD test indicates exposure to TB bacteria but does not distinguish between latent TB infection and active TB disease.
Correct Answer is B
Explanation
B. Pancreatitis is often associated with elevated serum amylase levels due to pancreatic inflammation. Therefore, this combination of clinical symptoms and laboratory findings is valuable in assessing the severity and confirming the diagnosis of pancreatitis.
A. While these are important clinical findings, they are not specific to pancreatitis and may not provide definitive information about the severity or cause of the condition.
C. Chronic constipation and serum gastrin levels are not typically associated with pancreatitis.
D. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly related to pancreatitis. H. pylori infection is associated with peptic ulcers and gastritis but not typically with pancreatitis.
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