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 C
Explanation
Choice A Reason:
Flossing between a 12-month-old's teeth is not typically necessary, as most children do not have enough teeth for flossing at this age. Flossing becomes more important as a child's dentition develops.
Choice B Reason:
Positioning the toothbrush bristles at a 90-degree angle is not appropriate for a 12-month-old child. Parents should use a gentle, circular brushing motion, as this is more effective and less likely to cause discomfort or injury to the child's gums and teeth.
Choice C Reason:
Cleaning the teeth with a small, soft-bristled toothbrush is correct. When teaching a parent about preventing dental caries in a 12-month-old toddler, it's important to provide appropriate guidance for oral care. Using a small, soft-bristled toothbrush is recommended for young children because it is gentle on their gums and teeth. Here's why the other options are not suitable:
Choice D Reason:
Using a 5-inch strip of toothpaste on the toothbrush is excessive for a 12-month-old. The American Academy of Pediatrics recommends using only a small smear or grain-sized amount of fluoride toothpaste for children under 3 years old to minimize the risk of swallowing too much fluoride.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.