A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute
The nurse's most appropriate action is to:
1. Give the medication
2. Ask if the client is anxious
3. Check the client's dressing for bleeding
4. Recheck the client's vital signs in 30 minutes
ANS: 1
The client's vital signs are consistent with the client being in pain. It would be safe and appropri-ate for the nurse to give the pain medication. Asking if the client is anxious is not the most ap-propriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Re-checking would not be the most appropriate action. The nurse should medicate the client for pain.
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