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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.
When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.
The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.
Correct Answer is C
Explanation
Choice A Reason:
Supine is incorrect. The supine position (lying flat on the back) is not the best choice because it can increase the risk of airway obstruction and discomfort, especially if there is swelling or drainage from the surgical site.
Choice B Reason:
Left lateral is incorrect. The left lateral position (lying on the left side) is not typically used after a thyroidectomy because it does not provide the same advantages for airway management, swelling reduction, and comfort as the semi-Fowler's position.
Choice C Raeson:
Semi-Fowler's position is the most appropriate choice for a client who is postoperative following a subtotal thyroidectomy for several reasons:
Airway Management: Elevating the head of the bed in a semi-Fowler's position helps maintain airway patency and reduces the risk of airway obstruction or compression of the surgical site, which is important for respiratory comfort and function.
Swelling and Drainage: After thyroid surgery, there may be swelling and drainage from the surgical site. The semi-Fowler's position can assist in reducing swelling and facilitating proper drainage.
Comfort: This position generally provides greater comfort for the client, especially when there may be discomfort or soreness at the surgical site.
Choice D Reason:
Dorsal recumbent is incorrect. The dorsal recumbent position (lying on the back with knees flexed and feet flat on the bed) is also not the most appropriate choice for post-thyroidectomy care because it does not offer the same benefits as the semi-Fowler's position in terms of airway management, swelling reduction, and comfort.
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