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 B
Explanation
Choice A Reason:
Documenting the administration of medications after all assigned clients have been medicated is generally a good practice but doesn't address medication safety directly.
Choice B Reason:
Checking the clients' allergy bands with each medication administration is correct. During a review of medication administration protocol, it is important to emphasize safety practices that help prevent medication errors and ensure the correct medication is administered to the right patient. Checking the clients' allergy bands with each medication administration is a crucial safety step to verify the patient's identity and confirm allergies. This practice helps prevent medication errors related to patient identification and allergies.
Choice C Reason:
Reading medication labels twice before administration is an important practice, but it's not specific to patient identification or allergy checking.
Choice D Reason:
Using one client identifier before administering medication is important, but it's just one aspect of ensuring patient identification. Checking allergy bands provides an additional layer of safety by confirming allergies, which can be crucial in preventing adverse reactions.
Correct Answer is A
Explanation
Choice A Reason:
Correct - Avoiding milk with the iron supplement is a good recommendation.
Choice B Reason:
Green tea contains tannins that can inhibit iron absorption, so it's not recommended to take iron with it.
Choice C Reason:
Berries and citrus fruits, while high in vitamin C, can actually enhance iron absorption, so there's no need to eliminate them from the diet.
Choice D Reason:
Increasing dietary fiber intake can be beneficial for overall health but does not have a direct effect on iron absorption.
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