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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Consuming dairy products, especially those rich in milk and cream, can stimulate gastric acid secretion and exacerbate symptoms of a duodenal ulcer. Therefore, it is essential for the nurse to review with the client the importance of avoiding foods that can aggravate the ulcer and worsen symptoms.

B. While reinforcing teaching about dietary modifications is important, encouraging the client to make a list of snack foods high in dairy content would not address the issue of avoiding dairy products to protect the duodenal ulcer.

C. While switching to decaffeinated coffee and tea can be beneficial for individuals with duodenal ulcers, it does not directly address the client's misconception about using dairy products to coat and protect the ulcer.

D. Eating frequent small meals can help reduce discomfort associated with duodenal ulcers by minimizing gastric acid secretion and preventing large fluctuations in stomach volume.

However, this option does not address the client's misconception.

A. Send blood for a complete blood count, electrolytes B. Enalapril 10 mg every morning C. C Ibuprofen 400 mg every 4 to 6 hours PRN for temperature greater than 100.5°F (38° C) D. Admit to the medical floor E. Supplemental oxygen 10 L/min via nasal cannula F. Vital signs every 4 hours G. Continuous pulse oximetry H. Chest x-ray

Correct Answer is ["C","E","H"]

Explanation

A. Send blood for a complete blood count, electrolytes: This is appropriate for assessing the client's overall health status and electrolyte balance, which may be affected by pneumonia and enalapril therapy.

B.Enalapril 10 mg every morning: This is the client's maintenance dose of enalapril for managing hypertension, and it should be continued unless there are specific contraindications or concerns about renal function.

C.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase blood pressure and interfere with the antihypertensive effects of enalapril. Additionally, NSAIDs can potentially worsen renal function, which may already be compromised in a client with pneumonia.
D.Admit to the medical floor: This is appropriate for a client with pneumonia who may require close monitoring and management of respiratory status and other complications.
E.Supplemental oxygen 10 L/min via nasal cannula: High-flow oxygen can decrease respiratory drive and potentially worsen ventilation-perfusion (V/Q) matching, especially in clients with pneumonia.

F.Vital signs every 4 hours: Regular monitoring of vital signs is essential for assessing the client's response to treatment and identifying any signs of deterioration.

G.Continuous pulse oximetry: Continuous pulse oximetry provides real-time monitoring of oxygen saturation and helps assess the effectiveness of oxygen therapy and the client's respiratory status.

H.While a chest x-ray is often indicated for diagnosing pneumonia, ordering it "now" may not be necessary unless the client's condition is unstable or if there are specific concerns regarding the severity of the pneumonia

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow- up action by the nurse?

Correct Answer is A

Explanation

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

Correct Answer is ["C","E","H"]

Explanation

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

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The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

An adult client is admitted with AIDS and oral Candide albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?