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?

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

Choice A Reason:

Changing a central venous catheter dressing for a client who is receiving IV therapy is correct. Sterile gloves should be used when performing procedures that involve the manipulation of sterile or aseptic areas, such as changing the dressing on a central venous catheter. Maintaining the sterility of the catheter site is crucial to prevent infections in clients receiving IV therapy through central lines.

Choice B Reason:

Instilling an ophthalmic ointment for a client with a corneal abrasion involves applying a medication to the eye is incorrect. While it's important to use clean technique and maintain good hand hygiene, it does not require sterile gloves.

Choice C Reason:

Inserting an NG (nasogastric) tube for enteral feedings is a clean procedure, not a sterile one. Clean gloves are typically used to maintain cleanliness and reduce the risk of infection, but full sterile technique is not necessary.

Choice D Reason:

Administering an IM (intramuscular) injection also does not require sterile gloves. Clean gloves should be used to maintain infection control, but full sterile technique is not needed for routine IM injections.