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 correct answer is choice C. Providing discharge teaching about home IV medication therapy.

Choice A rationale:

Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.

Choice B rationale:

Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.

Choice C rationale:

Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.

Choice D rationale:

Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.

A. Keep the finger in a dependent position:

• Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.

B. Wear sterile gloves:

• Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.

C. Select the central tip of a finger:

• The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.

D. Test the first drop of blood that forms after the puncture:

• The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.