a client has been receiving hydromorphone every six hours for four days what assessment should the nurse prioritize
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?

Correct answer: B

Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.

2. After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Before starting the urine collection, the nurse noted that the client's serum creatinine was 0.3 mg/dL. Which action should the nurse implement?

Correct answer: C

Rationale: A serum creatinine level of 0.3 mg/dL is abnormally low, indicating potential issues with the interpretation of the creatinine clearance test. It is crucial for the nurse to notify the healthcare provider of this result before proceeding with the 24-hour urine collection. Checking urine output, instructing the client to increase fluid intake, or starting the urine collection without consulting the healthcare provider could lead to incorrect test results and misinterpretation of the client's renal function.

3. A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?

Correct answer: B

Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.

4. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?

Correct answer: D

Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.

5. A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?

Correct answer: D

Rationale: Hyperemesis gravidarum, characterized by severe nausea and vomiting, leads to dehydration and electrolyte imbalances. The priority intervention is initiating IV fluids to correct these imbalances. Providing emotional support is important for the client's well-being, but addressing fluid and electrolyte imbalances takes precedence. Monitoring daily weight and encouraging small frequent meals are beneficial interventions but are not the priority when managing hyperemesis gravidarum.

Similar Questions

The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?
The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD). Which intervention is most important to promote effective breathing?
A client with chronic obstructive pulmonary disease (COPD) is experiencing difficulty breathing. What is the nurse's priority intervention?
A client has burns covering 40% of their total body surface area (TBSA). What is the nurse’s priority action?
The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses