A client 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; pulse, 90; and respirations, 26
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 client is anxious.
c. Check the client's dressing for bleeding.
d. Recheck the client's vital signs in 30 minutes.
A
The client's vital signs are consistent with the client being in pain (increased pulse, shallow breathing, and increased blood pressure). It would be safe and appropriate for the nurse to assess the client's pain on a pain scale and then administer the pain medication.
Asking if the client is anxious is not the most appropriate action.
The client is not demonstrating signs of shock (i.e., decreased blood pressure, increased pulse). Therefore the most appropriate action is not to check the client's dressing, but to administer pain medication.
Rechecking the client's vital signs in 30 minutes would not be the most appropriate action. The nurse should medicate the client for pain.
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