The nurse is assessing a postoperative client that reports a pain level of 10 on a 1 to 10 scale. The client is grimacing and appears anxious. Which of the following actions should the nurse perform first?
1. Administer pain medication if it has been longer than the ordered interval.
2. Offer to call the pastoral service to provide spiritual counseling.
3. Obtain an order for an anti-anxiety medication.
4. Call the family to come in and stay with the client.
1
Rationale 1: Pain needs to be well managed and pain should be assessed with vital signs. Pain is the 5th vital sign. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get "out of control." Once the pain is under control, the nurse can assess other factors influencing the client's pain response.
Rationale 2: Spiritual counseling may not be helpful if the pain is not managed effectively.
Rationale 3: Relieving the anxiety may help in alleviating pain and should be considered with other forms of pain management. However, relieving anxiety will be easier if the pain is managed effectively.
Rationale 4: The presence of family members may provide comfort to the client, but is not the priority intervention.
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Fill in the blank(s) with the appropriate word(s).