A patient complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs and finds them to be as follows: Blood pressure 134/92 mm Hg, pulse 90 beats per minute, and respirations 26 breaths per minute

Question

Which of the following is the nurse's most appropriate action? a. Assess with a pain scale, and administer the medication.
b. Ask if the patient is anxious.
c. Check the patient's dressing for bleeding.
d. Recheck the patient's vital signs in 30 minutes.

Answer 1

A

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A The patient's vital signs are consistent with the patient being in pain (increased pulse, shallow breathing, and increased blood pressure). It would be safe and appropriate for the nurse to assess the patient's pain on a pain scale and then administer the pain medication.
B Asking if the patient is anxious is not the most appropriate action.
C The patient is not demonstrating signs of shock (i.e., decreased blood pressure, increased pulse). Therefore, the most appropriate action is not to check the patient's dressing but to administer pain medication.
D Rechecking the patient's vital signs in 30 minutes would not be the most appropriate action. The nurse should medicate the patient for pain.