A nurse is reinforcing teaching with a guardian about receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse include as a potential effect of the medication?
Increased senses
Decreased sleep
Difficulty swallowing
Urinary frequency
The Correct Answer is D
A. Increased senses: PCA pump use, typically involving opioids, does not heighten the senses. Instead, opioids often dull sensory perception and can cause sedation rather than making sensations sharper or more intense.
B. Decreased sleep: Opioids used in PCA pumps often promote drowsiness and sleep rather than reducing it. Sleep disturbances are not a common direct effect of properly managed PCA analgesia unless pain remains uncontrolled.
C. Difficulty swallowing: Difficulty swallowing is not a usual side effect associated with PCA use. If it occurs, it would likely suggest another issue, such as a neurological problem, rather than a typical reaction to PCA-administered opioids.
D. Urinary frequency: Opioids can affect the bladder by either causing urinary retention or, less commonly, altering normal patterns. Clients receiving adequate hydration and pain management might experience urinary frequency, especially as mobility increases postoperatively.
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Related Questions
Correct Answer is C
Explanation
A. A client who requires sterile dressing changes every three hours: Sterile dressing changes require skilled nursing care and must be performed by a licensed nurse. An assistive personnel (AP) is not trained or authorized to perform sterile procedures, making this assignment inappropriate.
B. A client who has a small bowel obstruction and requires insertion of a nasogastric tube: Inserting a nasogastric tube is an invasive procedure that requires clinical judgment and proper technique, which are responsibilities of licensed nursing staff, not assistive personnel.
C. A client who is postoperative and requires intake and output measurement every 2 hr: Measuring and recording intake and output is within the scope of practice for assistive personnel. It is a routine, noninvasive task that does not require nursing assessment or judgment.
D. A client on hospice who is unstable and requires frequent vital sign checks: An unstable hospice client requires close monitoring and clinical assessment. Although assistive personnel can measure vital signs, evaluating changes and determining their significance must be done by licensed nursing staff.
Correct Answer is A
Explanation
A. Crackles in the lung bases: Left-sided heart failure leads to fluid buildup in the lungs due to the heart's inability to pump blood effectively. This fluid accumulation causes pulmonary congestion, which results in crackles, particularly in the lung bases. This is a common and expected finding in left-sided heart failure.
B. Anorexia: Anorexia may occur in heart failure, but it is not a primary or typical finding of left-sided heart failure. It is more commonly associated with right-sided heart failure, where digestive system congestion is more prevalent.
C. Bradycardia: Left-sided heart failure typically causes tachycardia (elevated heart rate) as the body compensates for the decreased cardiac output. Bradycardia is less commonly seen unless the client has an underlying arrhythmia or is on medications like beta-blockers.
D. Polyuria during the day: Polyuria, or excessive urination, is typically observed at night (nocturia) in clients with heart failure due to fluid redistribution when lying down. It is not commonly observed during the day.
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