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 B
Explanation
The infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.
The other options are not correct because:
A. Offering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.
C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.
D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.
Correct Answer is B
Explanation
The correct answer is choice B: Monitor the client's hearing. Choice A rationale:
Observing the skin for a rash is not relevant to assessing for signs of ototoxicity. Aminoglycosides can cause skin reactions, but this is not a specific sign of ototoxicity.
Choice B rationale:
Monitoring the client's hearing is essential when administering aminoglycosides because these medications can cause ototoxicity, which is damage to the inner ear and auditory nerve leading to hearing loss or tinnitus. Regular hearing assessments can help detect any changes in hearing and prompt appropriate interventions.
Choice C rationale:
Measuring the urinary output is not directly related to assessing for ototoxicity.
Aminoglycosides can cause kidney toxicity, but this is a separate concern from ototoxicity. Choice D rationale:
Checking for changes in vision is not specifically associated with aminoglycoside administration. Vision changes are not a common side effect of these medications, so it would not be a primary assessment in this situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.