A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

Correct answer: D

A.Sharing a client's substance use information with their employer without their consent may violate confidentiality and privacy laws.

B.Sharing information about a client's suicide with another nurse may be appropriate for staff who need to know for safety reasons but should be done carefully and only with those who have a legitimate need for the information.

C.Sharing a client's medical information with their partner in this scenario may be appropriate under certain circumstances. However, it's essential to consider the client's safety and well-being first. If the client has reported intimate partner abuse, the nurse must assess the risk of harm to the client if their partner is informed. Depending on the situation, it may be necessary to involve other healthcare professionals, such as social workers or law enforcement, to ensure the client's safety. Before sharing any information with the partner, the nurse should follow institutional policies and legal requirements, which often involve obtaining the client's consent or assessing the potential harm of disclosure.

D.Sharing a client's medical information with a social worker who is directly involved in the client's care is generally appropriate and often necessary for effective interdisciplinary collaboration. In this scenario, the social worker is assigned to the client and is likely involved in coordinating the client's care and support services. Sharing relevant medical information with the social worker can facilitate continuity of care and help ensure that the client's needs are met appropriately. However, it's essential for the nurse to adhere to confidentiality requirements and only share information on a need-to-know basis, ensuring that the information is used for the purpose of providing care and support to the client.

Choice A Reason:

A. Applying water-soluble lubricant to the site is not typically necessary for routine site care. It may be used during the initial insertion of the tube or when changing the tube, but it's not part of routine site care.

Choice B Reason:

B. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy tube. Securing the tube to the cheek may cause irritation or discomfort for the child and is not a secure method to prevent dislodgment.

Choice C Reason:

C. Attaching an extension tube to the site's opening prior to use may be necessary for feeding or medication administration, but it is not specific to site care. Site care primarily involves cleaning and inspecting the site and ensuring that the tube is secure.

Choice D Reason:

Securing the tubing to the child's abdomen is correct. When providing site care for a child with a gastrostomy enteral tube, it's essential to ensure that the tube is secured properly to prevent accidental dislodgment. Therefore, the nurse should secure the tubing to the child's abdomen using appropriate medical tape or a securement device.