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?

Choice A Reason:

"I will get you information about some head-covering options." This response shows empathy and a willingness to provide practical support to the client. It addresses the client's concerns about hair loss and offers assistance in finding head-covering options, which can be helpful during chemotherapy. It demonstrates a proactive and caring approach to the client's needs.

Choice B Reason:

"I wouldn't worry about this right now. Let's focus on your chemotherapy." This response dismisses the client's concerns and does not provide any support or information.

Choice C Reason:

"Let's discuss this when we have more time. “This response delays addressing the client's concerns and does not offer immediate support or information.

Choice D Reason:

"I can't imagine how difficult it would be to lose my hair." This response expresses personal empathy but does not offer practical assistance or information to the client about managing hair loss.

Correct answer: A

a.This step is crucial because it helps maintain the sterility of the kit by ensuring that the nurse does not accidentally contaminate the sterile field with their body or clothing.This step ensures that the nurse's hands and arms do not cross over the sterile field, reducing the risk of contamination.

b.Opening the flap nearest to the nurse first can lead to contamination because the nurse's hands and arms might cross over the sterile field while opening the remaining flaps. This increases the risk of introducing pathogens into the sterile area, compromising the sterility required for the procedure.

c.Opening a side flap first can also compromise the sterility of the field. Similar to option (b), this action might result in the nurse's hands or arms moving over the sterile area, risking contamination.

d.Applying sterile gloves is an essential step in maintaining sterility, but it is not the first step. The nurse needs to prepare the sterile field before donning sterile gloves to ensure that the gloves themselves remain uncontaminated. If the nurse were to put on sterile gloves first, there is a risk of contaminating the gloves while opening the sterile kit, thereby defeating the purpose of using sterile gloves.