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 D
Explanation
Choice A Reason:
Irrigation of a wound with antibiotic solution is incorrect. Typically, irrigation of a wound with antibiotic solution doesn't require informed consent unless there are specific factors or risks involved that require it. This is usually considered a routine wound care procedure.
Choice B Reason:
Administration of an iron injection using Z-track technique is incorrect. Informed consent may not be required for this procedure if it's a routine and commonly performed nursing intervention. However, if there are specific concerns or potential risks (e.g., allergy to the medication), informed consent might be necessary.
Choice C Reason:
Insertion of a nasogastric tube is correct. Insertion of a nasogastric tube generally requires informed consent, especially if it's a non-emergent procedure. Informed consent is essential because there can be risks associated with the insertion, and the client should be informed and agree to it.
Choice D Reason:
Placement of a central venous catheter is correct. Placement of a central venous catheter definitely requires informed consent. It's a more invasive procedure that involves entering a major blood vessel, and there are specific risks and potential complications associated with it.
Correct Answer is B
Explanation
Choice A Reason:
Prolonged PT/INR (prothrombin time/international normalized ratio) is not typically seen in pancreatitis. It may be indicative of liver dysfunction or issues with blood clotting.
Choice B Reason:
Elevated lipase levels are commonly seen in clients with pancreatitis. Lipase is an enzyme produced by the pancreas, and when there is inflammation or damage to the pancreas, such as in pancreatitis, it can lead to the release of lipase into the bloodstream. Therefore, an elevated lipase level is a typical laboratory finding in clients with pancreatitis.
Choice C Reason:
Elevated ammonia levels are not typically associated with pancreatitis. Elevated ammonia levels may be seen in clients with liver disease or other metabolic disorders.
Choice D Reason:
Decreased albumin levels are not typically associated with pancreatitis. Decreased albumin levels may be seen in clients with liver disease or malnutrition, but it is not a specific marker for pancreatitis.
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