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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:

"I might have occasional seizures for several days after the procedure." This statement is not accurate. ECT does induce a controlled seizure during the procedure, but clients typically do not experience seizures after the treatment. This statement does not indicate an understanding of the procedure.

Choice B Reason:

"I might have short-term memory loss after the procedure. “This statement is accurate. Memory loss is a common side effect of ECT, particularly short-term memory loss. It's important for the client to be aware of this potential side effect.

Choice C Reason:

"I will have a urinary catheter in place during the procedure." This statement is not accurate. A urinary catheter is not typically used during ECT. It's important for the client to have accurate information about the procedure.

Choice D Reason:

"I will need to follow a full-liquid diet for 24 hours after the procedure." This statement is not accurate. Clients undergoing ECT do not usually require a full-liquid diet afterward. The dietary restrictions may vary depending on the facility's policies, but it is not typically a full-liquid diet.

A. Coll the tubing on the bed above the collection bag B. Instruct the client to hold the drainage bag at waist height when ambulating C. Secure the tubing with adhesive tape to the lower abdomen. D. Collect a sterile specimen from the urinary drainage bag.

Correct Answer is C

Explanation

A) Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

B) Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

C) Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.

D) Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

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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

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