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. Isoniazid is an antitubercular medication commonly used in the treatment of active tuberculosis (TB). One of the primary goals of TB treatment is to reduce the symptoms associated with the infection, such as cough and sputum production.

B. While weight loss and decreased appetite can be symptoms of active tuberculosis, the goal of treatment with isoniazid is to improve symptoms and promote recovery.

C. A positive sputum smear and culture would indicate ongoing TB infection or treatment failure, rather than the effectiveness of isoniazid therapy.

D. Vertigo (dizziness) and tinnitus (ringing in the ears) are not typical side effects or outcomes associated with isoniazid therapy.

A. Obtain a pulse oximetry reading. B. Coach through using huff coughing. C. Attach humidification to oxygen delivery. D. Provide nebulizer breathing treatment.

Correct Answer is A

Explanation

A. Pulse oximetry measures the oxygen saturation of arterial blood, which is a crucial parameter to assess in clients with respiratory distress. Obtaining a pulse oximetry reading will provide information about the client's oxygenation status and help guide further interventions.

B. Huff coughing may be helpful for airway clearance but it may not be the most immediate intervention needed to address the client's respiratory distress.

C. Humidification may be beneficial for airway clearance in the long term but it may not be the most immediate intervention needed to address the client's acute respiratory distress.

D. Nebulizer breathing treatments, such as bronchodilators or corticosteroids, are commonly used to relieve bronchospasm and improve airflow in clients with COPD. However, in this scenario, the client's primary symptoms are dyspnea and tachypnea, indicating acute respiratory distress.

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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

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Correct Answer is A

Explanation

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

Correct Answer is A

Explanation

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