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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client tells the nurse he prefers a snack before bedtime: Client food preferences can usually be accommodated by nursing and dietary staff without needing interprofessional team intervention unless related to special dietary restrictions.
B. The client requires reinforcement of teaching about the purpose of his medications: Medication education reinforcement is a routine nursing responsibility and typically does not require escalation to the entire interprofessional team unless there are significant comprehension issues.
C. The client is unable to grasp eating utensils: Difficulty grasping utensils suggests significant motor deficits following the stroke. This functional limitation requires input from occupational therapy, physical therapy, and possibly speech therapy to assess needs for adaptive devices and rehabilitation strategies.
D. The client requests to perform ADLs later in the day: Adjusting the timing of ADLs is a minor scheduling preference and does not necessarily require interprofessional reporting unless it impacts therapy schedules or rehabilitation goals.
Correct Answer is D
Explanation
Rationale:
A. Triiodothyronine: Triiodothyronine (T3) measures thyroid function and is not related to anticoagulation therapy. It is important for evaluating thyroid disorders but has no role in monitoring the effects of warfarin.
B. Arterial blood gases: Arterial blood gases (ABGs) assess oxygenation, ventilation, and acid-base balance, not anticoagulation status. ABGs are not used to monitor warfarin therapy.
C. Serum potassium: Serum potassium levels are crucial for cardiac and muscle function but are not affected directly by warfarin use. Potassium monitoring is more critical with diuretics or certain cardiac medications, not anticoagulants like warfarin.
D. Prothrombin time: Prothrombin time (PT) measures how long it takes blood to clot and is directly affected by warfarin therapy. Monitoring PT (and the related INR) ensures that the warfarin dose maintains therapeutic anticoagulation without causing excessive bleeding.
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