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?

Choice A Reason:

Blaming the assistive personnel without additional information or evidence may not be appropriate and should be investigated further.

Choice B Reason:

Mentioning that an incident report has been completed and sent to risk management is important for institutional record-keeping and follow-up but does not provide details about the incident itself.

Choice C Reason:

"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'." In the documentation of a client fall, it is important to include the client's own account of the incident, as this can provide valuable information about the circumstances surrounding the fall. Including direct quotes or statements from the client helps to accurately capture their perspective and can be useful for assessing the root causes of the fall and developing appropriate interventions to prevent future falls.

Choice D Reason:

Documenting that the client does not appear to have any injuries is relevant but does not provide information about the circumstances of the fall, which is important for a comprehensive understanding of the event.

Choice A Reason:

Wiping from the outer to the inner canthus is not necessary and may cause contamination.

Choice B Reason:

Apply pressure to the lacrimal punctum after administering the drops. After administering eye drops to a child, it is important to gently apply pressure to the lacrimal punctum (located in the inner corner of the eye) for about 1-2 minutes. This helps prevent systemic absorption of the medication and reduces the risk of it going into the nasopharynx and digestive system. The other options are not recommended:

Choice C Reason:

Positioning the child side-lying is not typically required for administering eye drops.

Choice D Reason:

Rinsing the eye with normal saline before administering the drops is not a standard practice and is not recommended unless there is a specific reason to do so, such as eye irritation or foreign body removal.