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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

People with SLE are often sensitive to sunlight and should take precautions to protect their skin. Limiting time in the tanning bed is important because exposure to ultraviolet (UV) light can trigger or worsen symptoms of SLE. Using an astringent on the face and cleansing with an antibacterial soap may not be recommended for individuals with SLE, as these products can be harsh on the skin and may cause irritation. However, patting the skin dry with a towel is a gentle and appropriate method to dry the skin without causing unnecessary friction or irritation.

A. "You will have a leg bag to collect the urine." B. "You will feel pressure when I inflate the catheter balloon." C. "You cannot drink fluids for 4 hours after the procedure." D. "You will need to urinate before the procedure."

Correct Answer is D

Explanation

Choice A Reason:

Choice B Reason:

Inflating a catheter balloon is typically not part of intermittent catheterization, as it is more commonly associated with indwelling catheters.

Choice C Reason:

There is no need for the client to restrict fluid intake before or after intermittent catheterization. In fact, adequate hydration is generally encouraged.

Choice D Reason:

Intermittent catheterization involves inserting a catheter into the bladder to empty it completely, typically to measure residual urine. Before performing intermittent catheterization, it's essential for the client to try to urinate naturally to ensure that the bladder is as empty as possible. This step helps to provide accurate measurements of residual urine and reduces the risk of complications. Therefore, the nurse should include this information in the teaching to ensure the client understands the procedure's proper preparation. While the use of a leg bag to collect urine may be part of the overall management plan, it is not specific to the teaching about preparing for intermittent catheterization.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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