The practical nurse (PN) is caring for a client with fractured metatarsals after slamming a hand in the car door. After administering the prescribed hydrocodone/acetaminophen for pain, which intervention should the PN include in the client's care?
Implement ongoing assessments for signs of shallow or slow breathing.
Assess the skin daily for areas of ecchymosis or other signs of bleeding.
Encourage the client to resume normal activities after medication administration.
Observe the client for involuntary movements of the lips and tongue.
The Correct Answer is A
Choice A rationale:
After administering hydrocodone/acetaminophen for pain, the PN should closely monitor the client for signs of respiratory depression, which may manifest as shallow or slow breathing.
Ongoing assessments are crucial because respiratory depression is a potential adverse effect of opioid medications like hydrocodone. If this complication is detected early, appropriate interventions can be implemented to ensure the client's safety.
Choice B rationale:
Assessing the skin daily for areas of ecchymosis or other signs of bleeding is not directly related to the administration of hydrocodone/acetaminophen. While bruising and bleeding are possible side effects of some medications, this assessment is not the priority in this scenario.
Choice C rationale:
Encouraging the client to resume normal activities after medication administration is not appropriate in this situation. Hydrocodone/acetaminophen can cause drowsiness and impairment, so the client should be advised to avoid activities that require alertness or coordination until the effects of the medication are known.
Choice D rationale:
Observing the client for involuntary movements of the lips and tongue is relevant when administering antipsychotic medications, as these movements may be signs of tardive dyskinesia. However, it is not directly related to the use of hydrocodone/acetaminophen. The priority after administering this pain medication is to monitor for respiratory depression, as opioids can affect the respiratory system
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct Answer: C. Measure the next voiding, then palpate the client's bladder.
Choice A rationale:
Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.
Choice B rationale:
Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.
Choice C rationale:
Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.
Choice D rationale:
Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.
Correct Answer is B
Explanation
PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.
The other options are not correct because:
A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.
C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.
D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.
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