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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. In the case of oral candidiasis, using a toothbrush with soft bristles is essential to prevent further irritation and damage to the already compromised oral mucosa.
A. Offering the client mouthwash for thorough cleansing after brushing teeth might not be appropriate. Many commercial mouthwashes contain alcohol, which can further irritate the oral mucosa and exacerbate the symptoms of oral candidiasis.
B. Assisting with personal care but leaving oral care for the nurse to complete is not the best option. Oral care is an essential aspect of hygiene, especially for someone with oral candidiasis.
D. Oral candidiasis is a fungal infection that is not typically transmitted through contact,
Correct Answer is C
Explanation
C. After eye surgery, especially when there's been trauma like glass removal, it's crucial to protect the eye from further injury, particularly during sleep when movements may be involuntary and less controlled. An eye shield helps prevent inadvertent rubbing or trauma to the eye, promoting healing and reducing the risk of complications.
A. While deep breathing and coughing exercises are important for preventing respiratory complications after surgery, they are not the immediate intervention required following surgical removal of glass from the eye.
B. Monitoring vital signs is essential for assessing the client's overall health status and detecting any signs of complications. However, it is not a priority
D. While administering eye drops may be a part of postoperative care, it's not the immediate intervention required right after the surgical removal of glass from the eye.
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