Exhibits

A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Cliick on the exhibit tabs for additional information about t three tabs that contain separate categories of data.)

Rationale:

A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.

B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.

C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.

D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.

Rationale:

A. "You should appoint a family member as your health care surrogate.": While clients may choose a family member, they are not required to do so. The decision is personal, and clients can appoint anyone they trust, regardless of relation, to serve as their health care surrogate.

B. "Once you have completed a living will, it cannot be changed.": A living will can be revised or revoked at any time by the client as long as they remain mentally competent. Clients retain the right to alter their advance directives based on changes in preferences or health status.

C. "You will need an attorney to appoint a health care surrogate.": Appointing a health care surrogate does not require an attorney. Most states allow individuals to complete this process using standardized forms and witnesses, without the need for legal representation.

D. "Your health care surrogate will make decisions on your behalf if you are unable.": A health care surrogate is authorized to make medical decisions when the client is no longer capable of doing so. This ensures that the client’s preferences are respected even if they become incapacitated.