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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Deep breathing and coughing exercises are not a priority intervention immediately following eye surgery. They are more commonly used to prevent postoperative pulmonary complications, such as pneumonia or atelectasis, in patients who have undergone general anesthesia or have respiratory conditions.
While deep breathing and coughing exercises can help promote circulation and prevent blood clots, they are not directly relevant to protecting the eye after surgery.
Engaging in deep breathing and coughing exercises too soon after eye surgery could potentially increase intraocular pressure, which could strain the healing eye and potentially lead to complications.
Choice B rationale:
Obtaining vital signs every 2 hours is a standard nursing intervention for monitoring a patient's overall condition, but it is not the most immediate priority following eye surgery.
Vital signs can provide important information about the patient's heart rate, blood pressure, respiratory rate, and temperature, but they do not directly address the protection of the surgically treated eye.
While monitoring vital signs is important, it does not specifically address the prevention of injury or complications to the eye itself.
Choice C rationale:
Providing an eye shield is the most crucial intervention to protect the eye immediately following surgery. The eye shield serves several important purposes:
Protection from accidental injury: It prevents the patient from accidentally rubbing or bumping the eye during sleep, which could cause further damage or disrupt the healing process.
Prevention of infection: It helps to keep the eye clean and free from debris, reducing the risk of infection. Reduction of swelling: It can help to minimize swelling and discomfort by applying gentle pressure to the eye area.
Promotion of healing: By creating a dark and protected environment, the eye shield can promote rest and healing of the tissues.
Choice D rationale:
Teaching a family member to administer eye drops is an important intervention for long-term care, but it is not the most immediate priority following surgery.
The patient may be able to administer eye drops independently, or a nurse may be responsible for administering them in the initial post-operative period.
Focusing on teaching family members about eye drop administration right after surgery could distract from more urgent priorities, such as protecting the eye with an eye shield.
Correct Answer is C
Explanation
Choice A rationale:
Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.
Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.
Choice B rationale:
While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.
The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.
Choice C rationale:
Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.
This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.
The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.
This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.
Choice D rationale:
Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.
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