A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc.

Which of the following findings should the nurse identify as an indicator of unrelieved pain?

Coiling the tubing on the bed above the collection bag helps to prevent the backflow of urine and maintains the integrity of the drainage system. This positioning allows for proper gravity drainage and prevents urine from pooling in the tubing.

Instructing the client to hold the drainage bag at waist height helps to ensure proper urine flow and prevent tension or pulling on the catheter. This positioning also prevents the bag from dragging on the floor, reducing the risk of contamination or accidental disconnection.

Securing the tubing with adhesive tape to the lower abdomen helps to prevent accidental pulling or dislodgment of the catheter. This ensures that the catheter remains in place and minimizes the risk of trauma or discomfort for the client.

If a sterile urine specimen is required, it should be collected using a separate sterile container and not directly from the urinary drainage bag. The drainage bag may contain contaminants or non-sterile elements, so a separate specimen collection method should be employed to ensure accuracy and prevent contamination.

Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.

The other options listed are incorrect:

1. Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed on clients with DVT.
2. Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
3. Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.