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 A
Explanation
Choice A Reason:
"I would like to observe you using your glucometer. “To evaluate the client's use of a glucometer effectively, the nurse should ask the client to demonstrate how they use the device to check their blood glucose levels. This allows the nurse to directly observe the client's technique, including proper hand hygiene, fingerstick procedure, test strip insertion, and interpretation of results. It also provides an opportunity to correct any errors or misconceptions in real-time and ensure the client is using the glucometer correctly.
Choice B Reason:
"Show me what blood glucose supplies you have available." This question assesses the client's supply inventory but does not assess their actual use of the glucometer.
Choice C Reason:
"Let me demonstrate for you how to use this machine correctly." This option involves the nurse demonstrating the use of the glucometer to the client, which may be helpful as part of teaching but does not evaluate the client's current proficiency in using the device.
Choice D Reason:
"Tell me how long you have been using this glucometer." This question inquiries about the client's history of using the glucometer but does not assess their current competence in using it.
Correct Answer is D
Explanation
Choice A Reason:
Applying warm, moist packs to the surgical site may not be indicated as it can potentially increase swelling and disrupt the surgical site.
Choice B Reason:
Massaging the lower leg in smooth, long strokes is generally not recommended in the early postoperative period, as it can disturb the surgical site and potentially lead to complications.
Choice C Reason:
When planning care for a client who is postoperative following a knee arthroplasty, placing a pillow under the surgical knee can be beneficial. This helps maintain proper alignment, reduces pressure on the surgical site, and promotes comfort and circulation. Elevating the leg slightly with a pillow can also help reduce swelling and minimize the risk of complications such as deep vein thrombosis (DVT).
Choice D Reason:
Using the continuous passive-motion (CPM) machine intermittently should be done as ordered by the healthcare provider and under their guidance.CPM is typically initiatedearly postoperatively, often within the first 24 hours after surgery.
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