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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?

Urinary retention

Constipation

Difficulty swallowing

Clenched teeth

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Urinary retention can be a side effect of opioids used in PCA, but it is not a direct indicator of unrelieved pain.

Choice B Reason:

Constipation is a potential side effect of opioid medications, but it does not directly indicate unrelieved pain.

Choice C Reason:

Difficulty swallowing is not a typical indicator of unrelieved pain but may be related to other factors such as postoperative effects or medication side effects.

Choice D Reason:

Clenched teeth can be an indicator of unrelieved pain in a client receiving patient-controlled analgesia (PCA). It suggests that the client is experiencing discomfort and may be trying to endure the pain rather than using the PCA pump to self-administer pain relief. Clients who are in pain may clench their teeth as a response to pain or discomfort.

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Correct Answer is B

Explanation

Choice A Reason:

Improved respiratory function is incorrect. Pancrelipase primarily helps with the digestion and absorption of fats and fat-soluble vitamins. It does not directly impact respiratory function. Respiratory improvement in cystic fibrosis typically involves treatments such as airway clearance techniques, bronchodilators, and antibiotics to manage lung infections.

Choice B Reason:

Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy used to treat individuals with cystic fibrosis, a condition that affects the pancreas's ability to produce digestive enzymes. Cystic fibrosis leads to the malabsorption of nutrients, especially fats. Pancrelipase supplements these digestive enzymes and helps the child digest and absorb fat properly. As a result, one of the expected therapeutic effects of pancrelipase is a reduction in fat in the stools, as the enzymes aid in the digestion of dietary fats, leading to improved absorption of nutrients. This, in turn, can help address malnutrition and promote overall health in individuals with cystic fibrosis.

Choice C Reason:

Improved absorption of vitamins B and C is incorrect. While pancrelipase can help with the absorption of fat-soluble vitamins (A, D, E, and K), it does not directly affect the absorption of vitamins B and C, which are water-soluble vitamins. Cystic fibrosis primarily affects the absorption of fat-soluble vitamins due to impaired fat digestion.

Choice D Reason:

Decreased sodium excretion is incorrect. Cystic fibrosis is associated with excessive loss of salt (sodium chloride) in sweat. Pancrelipase does not directly affect sodium excretion. Treatment for managing sodium loss typically involves salt supplementation and ensuring proper hydration.

A. Assist the client to the orthopneic position. B. Instruct the client to remain as still as possible during the recording. C. Attach a blood pressure cuff to the client's upper arm. D. Tell the client to expect a mild stinging sensation during the test.

Correct Answer is B

Explanation

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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