A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc.

Which of the following findings should the nurse identify as an indicator of unrelieved pain?

Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.

Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.
Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence.
Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.

Incident report

In the given scenario, where the nurse inadvertently administers 2 tablets of acetaminophen with codeine instead of the prescribed dose of 1 tablet, the nurse should document this client care incident in an incident report.

An incident report is a formal record that documents any unexpected or adverse events that occur during the provision of healthcare. It serves as a tool for identifying and addressing potential risks and improving patient safety. The incident report should include a detailed account of what happened, including the date, time, individuals involved, description of the incident, and any potential harm or actual harm caused to the client. It should be completed as soon as possible after the incident occurs.

Provider's progress notes in (option A) is incorrect: Provider's progress notes are used to document the healthcare provider's assessment, diagnosis, treatment plan, and progress of the client's condition. It is not the appropriate place to document a client care incident like an administration error.

Controlled substance inventory record in (option C) is incorrect: The controlled substance inventory record is used to track the use and documentation of controlled substances in a healthcare facility. While medication errors involving controlled substances should be reported and documented, the controlled substance inventory record is not the appropriate place for documenting a client care incident.

Nursing care plan in (option D) is incorrect: The nursing care plan outlines the client's nursing diagnoses, goals, and nursing interventions. It is not the appropriate place to document a client care incident like a medication administration error.