The nurse admits an older male patient who had abdominal surgery. Admission vital signs are P 73, R 20, BP 136/84 mm Hg. He is receiving intravenous (IV) fluids but has not re-quested pain medication since surgery
Seven hours later, his vital signs are P 98, R 26, BP 164/90 mm Hg, and he denies pain. Which intervention should the nurse implement? a. Administer an opioid medication by IV route.
b. Check the surgical dressing for bleeding.
c. Report the vital signs to the health care provider.
d. Ask him about discomfort at the surgical site.
D
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A Incorrect. This is unethical; the nurse should avoid administering medication for pain without the patient's request.
B Incorrect. The patient shows signs of pain rather than blood loss.
C Incorrect. It is premature for the nurse to report the vital signs because the pa-tient's pain assessment is not complete.
D Correct. The patient's heart rate, respiratory rate, and blood pressure increased significantly since the admission vital signs, and indicate the potential for patient pain or discomfort from the surgical incision. The patient can be misun-derstanding the nurse's question or be barred from saying yes by cultural pat-terns. Such miscommunication is common, so the nurse rewords the question using another term for pain such as discomfort, burning, or pressure.
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