The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Observe for edema around the ankles.

Count the apical and radial pulses simultaneously.

Measure the patient’s capillary glucose level.

Auscultate the patient’s bowel sounds.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

Observing for edema around the ankles is a relevant assessment, but it's not the most crucial one in this context. Edema can be a sign of fluid retention, which is a potential side effect of hydromorphone. However, it's not the most immediate or dangerous concern associated with prolonged hydromorphone use.

Rationale for Choice B:

Counting the apical and radial pulses simultaneously is a technique used to assess for pulse deficits, which can indicate heart rhythm irregularities. While hydromorphone can potentially cause cardiac effects, it's not the most common or primary concern with its use. Other assessments take priority.

Rationale for Choice C:

Measuring the patient's capillary glucose level is important for patients with diabetes or those at risk for hyperglycemia. However, there's no direct link between hydromorphone use and blood glucose levels. This assessment isn't the most relevant in this specific scenario.

Rationale for Choice D:

Auscultating the patient's bowel sounds is the most important assessment for a patient who has been receiving hydromorphone for four days. Here's why:

Hydromorphone is a potent opioid analgesic that can significantly slow down gastrointestinal motility. This can lead to constipation, which, if severe, can progress to ileus (a complete lack of bowel movement).

Ileus is a serious complication that can cause abdominal pain, bloating, nausea, vomiting, and even bowel obstruction or perforation if left untreated.

Auscultating bowel sounds helps assess the patient's bowel activity and detect early signs of constipation or ileus. Normal bowel sounds are typically heard every 5-15 seconds. Decreased or absent bowel sounds can indicate decreased bowel activity.

Early identification of constipation or ileus allows for prompt intervention, such as increasing fluid and fiber intake, administering laxatives or stool softeners, and potentially discontinuing or adjusting the hydromorphone dosage. This can prevent the development of more serious complications.

Therefore, auscultating the patient's bowel sounds is the most important assessment for the nurse to complete in this case, as it directly addresses the most significant potential complication associated with prolonged hydromorphone use.

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Correct Answer is B

Explanation

Choice A rationale:

Colloidal oatmeal-based lotions can be soothing and moisturizing for dry, itchy skin, but they are not effective in treating the inflammation and scaling associated with psoriasis.

They do not address the underlying hyperproliferation of skin cells that is characteristic of psoriasis.

While they may provide temporary relief of symptoms, they are not a long-term solution for managing the condition.

Choice B rationale:

Topical corticosteroids are the mainstay of treatment for psoriasis.

They work by reducing inflammation, slowing the growth of skin cells, and easing itching and scaling. They come in a variety of strengths and formulations, including creams, ointments, gels, and foams.

The type of corticosteroid and the strength of the medication will depend on the severity of the psoriasis and the location of the lesions.

It's important to follow the healthcare provider's instructions for use carefully, as overuse of topical corticosteroids can lead to side effects such as thinning of the skin and rebound flares.

Choice C rationale:

Topical analgesics, such as lidocaine or benzocaine, can be used to temporarily relieve pain and itching associated with psoriasis.

However, they do not address the underlying inflammation and scaling, and they should not be used as a primary treatment for the condition.

They may be used as adjunctive therapy in conjunction with topical corticosteroids or other psoriasis medications.

Choice D rationale:

Topical antifungal medications are used to treat fungal infections of the skin, such as athlete's foot or ringworm. They are not effective in treating psoriasis, which is an autoimmune condition rather than a fungal infection.

Using a topical antifungal medication for psoriasis could potentially worsen the condition or lead to other skin problems.

A. Radiation exposure B. Corneal abrasion C. Chemical burn D. Foreign body

Correct Answer is B

Explanation

Choice A rationale:

Radiation exposure to the eye is a serious condition that requires immediate medical attention. However, it is not a contraindication for ophthalmic ketorolac. In fact, ketorolac may be used to treat pain and inflammation associated with radiation exposure to the eye.

Ophthalmic ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are substances that cause inflammation and pain.

Radiation exposure can damage the cells of the eye, leading to inflammation and pain. Ketorolac can help to reduce these symptoms.

However, it is important to note that ketorolac does not address the underlying cause of radiation exposure, and further treatment may be necessary.

Choice B rationale:

Corneal abrasion is a scratch on the surface of the cornea, the clear outer layer of the eye. It is a common eye injury that can be caused by a variety of factors, such as getting poked in the eye, rubbing the eye too hard, or wearing contact lenses for too long.

Ophthalmic ketorolac is contraindicated in patients with corneal abrasions because it can delay healing and increase the risk of infection.

This is because ketorolac inhibits the production of prostaglandins, which are involved in the healing process. Prostaglandins also play a role in fighting infection.

Therefore, using ketorolac in a patient with a corneal abrasion could potentially lead to a more serious infection.

Choice C rationale:

Chemical burn to the eye is a serious injury that requires immediate medical attention. Ophthalmic ketorolac is not typically used to treat chemical burns to the eye.

This is because ketorolac is not effective in reducing inflammation caused by chemical burns. In addition, ketorolac can potentially worsen the injury by delaying healing.

Choice D rationale:

Foreign body in the eye is a common eye injury that can be caused by a variety of objects, such as dust, sand, or metal shavings. Ophthalmic ketorolac is not typically used to treat foreign bodies in the eye.

This is because ketorolac will not help to remove the foreign body from the eye. In addition, ketorolac can potentially worsen the injury by delaying healing.

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The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Nursing Test Bank

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