A client has been in a motor vehicle accident and sustained significant injuries. The client is in shock and is semi-conscious, but is restless and moaning
The family is concerned the client is in pain and demands the nurse administer ordered morphine. The priority action by the nurse is to a. check the client's oxygen saturation.
b. give morphine as ordered, slowly.
c. politely decline their request.
d. reposition the client.
A
Restlessness must be evaluated carefully, because it can signify both hypoxia and pain. While trauma clients must have their pain attended to, nurses must use opioids cautiously because they cause hypotension, further exacerbating shock. The first action by the nurse should be to check on the client's oxygenation status. If the client's oxygenation status is stable, the nurse should try positioning and other comfort measures as allowed by the client's condition before using opioids. The nurse should not simply decline the family's request; the nurse needs to educate the family as to the concerns and continue to provide high-caliber care. When opioids are used, they should be given IV, in small amounts, and given slowly.
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