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?

Clenched teeth

Difficulty swallowing

Constipation

Urinary retention

Answer and Explanation

The Correct Answer is A

The correct answer is A.

Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.

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Correct Answer is C

Explanation

The correct answer is choice C. Providing discharge teaching about home IV medication therapy.

Choice A rationale:

Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.

Choice B rationale:

Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.

Choice C rationale:

Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.

Choice D rationale:

Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.

A. Instruct the client to cough every 4 hr. B. Encourage the client to ambulate to loosen secretions. C. Maintain the client in high-Fowler's position. D. Increase the client's intake of oral fluids.

Correct Answer is C

Explanation

The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.

This can help alleviate dyspnea and improve oxygenation in clients with heart failure.

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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 planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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