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 C
Explanation
Choice A Reason:
Increasing the flow rate without healthcare provider guidance can be dangerous and should not be done without proper instruction.
Choice B Reason:
Synthetic blankets can generate static electricity, which poses a fire hazard in the presence of oxygen. Clients using oxygen therapy should be advised to use cotton or wool blankets that are less likely to generate static.
Choice C Reason:
"I will check my oxygen equipment at least once daily." This statement indicates an understanding of the importance of equipment safety and maintenance in home oxygen therapy. Regularly checking oxygen equipment for proper functioning is essential for the client's safety. It helps ensure that the oxygen delivery system is working correctly and that there are no issues with flow rate or oxygen concentration.
Choice D Reason:
Isopropyl alcohol is flammable and should not be used to clean oxygen equipment due to the risk of ignition in the presence of oxygen. Clients should use mild soap and water for cleaning nasal cannulas and other equipment.
Correct Answer is B
Explanation
Choice A Reason:
Presenting information from complex to simple: While it's important to simplify complex medical information, presenting it from complex to simple in a brochure may not be the best approach for general public education. Starting with complex information could potentially overwhelm and confuse readers.
Choice B Reason:
Write the information at an 8th-grade reading level is correct. When developing educational materials like brochures for the community, it's important to use language that is easily understandable by the target audience. Writing the information at an 8th-grade reading level ensures that the content is accessible to a wide range of individuals with varying levels of education and literacy. This approach promotes effective communication and helps ensure that more people can access and understand the information about hypertension and its management.
Choice C Reason:
Explaining medical terminology using basic, one-syllable words: While simplifying medical terminology is essential, using only one-syllable words may oversimplify the content and may not adequately convey important information about hypertension.
Choice D Reason:
Using a 12-point font size: Font size is important for readability, but using a specific font size like 12-point may not be sufficient on its own to ensure readability. Factors such as the choice of font style, spacing, and layout are also critical for making the brochure easy to read.
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