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?
Urinary retention
Constipation
Difficulty swallowing
Clenched teeth
The Correct Answer is D
Choice A Reason:
Urinary retention can be a side effect of opioids used in PCA, but it is not a direct indicator of unrelieved pain.
Choice B Reason:
Constipation is a potential side effect of opioid medications, but it does not directly indicate unrelieved pain.
Choice C Reason:
Difficulty swallowing is not a typical indicator of unrelieved pain but may be related to other factors such as postoperative effects or medication side effects.
Choice D Reason:
Clenched teeth can be an indicator of unrelieved pain in a client receiving patient-controlled analgesia (PCA). It suggests that the client is experiencing discomfort and may be trying to endure the pain rather than using the PCA pump to self-administer pain relief. Clients who are in pain may clench their teeth as a response to pain or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will no longer be able to eat nuts." While it's essential to be cautious about certain foods after a colostomy, avoiding nuts altogether may not be necessary. The client should discuss dietary restrictions with their healthcare provider or a registered dietitian.
Choice B Reason:
"I will empty the pouch every 2 to 3 hours." The frequency of pouch emptying can vary depending on the client's individual needs and the ostomy type. There's no fixed schedule for emptying the pouch, so this statement is not necessarily accurate.
Choice C Reason:
"I should expect my stool to be formed." The consistency of stool from a colostomy can vary depending on the location of the stoma and the type of colostomy. It may be formed or semi-formed, but it can also be more liquid or loose, depending on the circumstances. The client should
Choice D Reason:
"I will notify my doctor if the stoma starts to look purple." This statement reflects the client's awareness of the importance of monitoring the stoma's color and seeking medical attention if it appears discolored or compromised. A purple or dark-colored stoma can indicate inadequate blood supply, which is a concern that should be addressed promptly.
discuss stool consistency with their healthcare provider.
Correct Answer is D
Explanation
Choice A Reason:
A. Applying water-soluble lubricant to the site is not typically necessary for routine site care. It may be used during the initial insertion of the tube or when changing the tube, but it's not part of routine site care.
Choice B Reason:
B. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy tube. Securing the tube to the cheek may cause irritation or discomfort for the child and is not a secure method to prevent dislodgment.
Choice C Reason:
C. Attaching an extension tube to the site's opening prior to use may be necessary for feeding or medication administration, but it is not specific to site care. Site care primarily involves cleaning and inspecting the site and ensuring that the tube is secure.
Choice D Reason:
Securing the tubing to the child's abdomen is correct. When providing site care for a child with a gastrostomy enteral tube, it's essential to ensure that the tube is secured properly to prevent accidental dislodgment. Therefore, the nurse should secure the tubing to the child's abdomen using appropriate medical tape or a securement device.
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