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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 C

Explanation

c. Roasted salmon

The nurse should include roasted salmon on the tray for the client who follows a kosher diet.

Kosher dietary laws prohibit the consumption of shellfish such as clams and shrimp, as well as pork products like pulled pork sandwiches. Roasted salmon, on the other hand, is a permissible food item in a kosher diet.

It's important for the nurse to be aware of the client's dietary restrictions and preferences to ensure that they receive appropriate and culturally sensitive care.

A. Document the infiltration. B. Elevate the arm. C. Apply a warm compress. D. Stop the infusion.

Correct Answer is D

Explanation

Choice A Reason:

Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.

Choice B Reason:

Elevating the arm can help reduce swelling, but it should come after stopping the infusion.

Choice C Reason:

Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.

Choice D Reason:

Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.

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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 caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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