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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Choice B Reason:

Inflating a catheter balloon is typically not part of intermittent catheterization, as it is more commonly associated with indwelling catheters.

Choice C Reason:

There is no need for the client to restrict fluid intake before or after intermittent catheterization. In fact, adequate hydration is generally encouraged.

Choice D Reason:

Intermittent catheterization involves inserting a catheter into the bladder to empty it completely, typically to measure residual urine. Before performing intermittent catheterization, it's essential for the client to try to urinate naturally to ensure that the bladder is as empty as possible. This step helps to provide accurate measurements of residual urine and reduces the risk of complications. Therefore, the nurse should include this information in the teaching to ensure the client understands the procedure's proper preparation. While the use of a leg bag to collect urine may be part of the overall management plan, it is not specific to the teaching about preparing for intermittent catheterization.

A. "Apply talcum powder daily after bathing in order to prevent diaper rash." B. "Ensure the bath water is at least 96 degrees Fahrenheit." C. "Perform sponge baths until the baby's umbilical cord falls off." D. "Use an alkaline soap to bathe the baby."

Correct Answer is C

Explanation

Choice A Reason:

Applying talcum powder daily after bathing is not recommended, as it can pose a risk to the baby's respiratory health if inhaled.

Choice B Reason:

The water for a baby's bath should be comfortably warm, but it should not be as hot as 96 degrees Fahrenheit, as this can scald the baby's delicate skin.

Choice C Reason:

"Perform sponge baths until the baby's umbilical cord falls off." This is true. This is because newborns typically receive sponge baths until their umbilical cord stump naturally falls off, which usually occurs within the first few weeks of life. It's important to keep the area around the umbilical cord clean and dry to prevent infection. The other options are not recommended:

Choice D Reason:

Using an alkaline soap is not recommended for newborns, as their skin is sensitive. Mild, fragrance-free, and pH-balanced baby soap is typically recommended for baby's bath.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?

Correct Answer is C

Explanation

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