Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?
A. Urinary retention
Opioid medications can cause urinary retention by inhibiting the normal function of the bladder and reducing the urge to urinate. This can lead to incomplete emptying of the bladder and increased urine retention. Nurses should monitor clients receiving opioids for signs of urinary retention, such as decreased urine output, distended bladder, or discomfort in the lower abdomen.
B. Dilated pupils
Opioids generally cause pupil constriction (miosis) rather than dilation (mydriasis). Dilated pupils may indicate other drug use or neurological issues, but they are not a typical adverse effect of hydromorphone.
C. Hypertension
Hydromorphone is more likely to cause hypotension (low blood pressure) as an adverse effect rather than hypertension (high blood pressure).
D. Tachypnea
Hydromorphone can cause respiratory depression, which is characterized by decreased respiratory rate and depth. Tachypnea (rapid breathing) is not a typical adverse effect of hydromorphone.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Opioid medications can cause urinary retention by inhibiting the normal function of the bladder and reducing the urge to urinate. This can lead to incomplete emptying of the bladder and increased urine retention. Nurses should monitor clients receiving opioids for signs of urinary retention, such as decreased urine output, distended bladder, or discomfort in the lower abdomen.
Opioids generally cause pupil constriction (miosis) rather than dilation (mydriasis). Dilated pupils may indicate other drug use or neurological issues, but they are not a typical adverse effect of hydromorphone.
Hydromorphone is more likely to cause hypotension (low blood pressure) as an adverse effect rather than hypertension (high blood pressure).
Hydromorphone can cause respiratory depression, which is characterized by decreased respiratory rate and depth. Tachypnea (rapid breathing) is not a typical adverse effect of hydromorphone.
Similar Questions
A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?
A. Use lemon glycerin swabs.
Acidic, spicy, or crunchy foods should be avoided. Using lemon glycerin swabs can irritate the oral mucosa, so they should not be used.
B. Consume soft, bland foods.
Stomatitis is an inflammation of the oral mucosa, which can cause pain, discomfort, and difficulty eating. To manage stomatitis, clients should consume soft, bland foods that are easy to chew and swallow, such as cooked vegetables, mashed potatoes, and oatmeal.
C. Rinse the mouth with an alcohol-based mouthwash.
Mouthwashes containing alcohol can cause further irritation, so they should also be avoided.
D. Eat foods high in vitamin B12The correct answer is B
Eating foods high in vitamin B12 can be helpful for preventing stomatitis, but it is not an appropriate intervention for managing an existing case of stomatitis.
Full Explanation
Stomatitis is an inflammation of the oral mucosa, which can cause pain, discomfort, and difficulty eating. To manage stomatitis, clients should consume soft, bland foods that are easy to chew and swallow, such as cooked vegetables, mashed potatoes, and oatmeal.
Acidic, spicy, or crunchy foods should be avoided. Using lemon glycerin swabs can irritate the oral mucosa, so they should not be used.
Mouthwashes containing alcohol can cause further irritation, so they should also be avoided. Eating foods high in vitamin B12 can be helpful for preventing stomatitis, but it is not an appropriate intervention for managing an existing case of stomatitis.
A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning. Which of the following actions should the nurse take?
A. Plug the IV pump's cord into a different outlet.
B. Clear the settings and reset the IV pump.
C. Discontinue use and tag the IV pump.
A malfunctioning IV pump screen poses a risk to the accurate administration of IV fluids and medications, and it can compromise patient safety. It is important to discontinue use of the malfunctioning pump to prevent potential errors or complications. The nurse should tag the IV pump to notify others that it is not functioning properly and should not be used until it is repaired or replaced.
D. Replace the IV pump's tubing.
Full Explanation
A malfunctioning IV pump screen poses a risk to the accurate administration of IV fluids and medications, and it can compromise patient safety. It is important to discontinue use of the malfunctioning pump to prevent potential errors or complications. The nurse should tag the IV pump to notify others that it is not functioning properly and should not be used until it is repaired or replaced.
A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA).
Which of the following actions should the nurse take?
A. Have the client's partner sign an AMA form
Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.
B. Discharge the client and notify the health care provider.
Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.
C. Ask the partner to reiterate the consequences of leaving AMA to the client.
Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.
D. Request the services of an interpreter to determine the client's wishes.
Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.
Full Explanation
Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.
Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.
Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.
Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.