Question

During morning report, the nurse is told that the postoperative client has complained of unremitting pain during the night. Although she has been given pain medication several times, there seems to be no change in the client's condition. Which action should the nurse take at this time? A. Call the doctor and ask for a change in the client's medication B. Perform a head-to-toe assessment C. Administer another dose of the client's prescribed analgesic D. Ask the client whether she is addicted to pain medications

Short answer

Answer: B. Perform a head-to-toe assessment.

Step-by-step solution

Read the situation carefully

Read the given situation and understand the problem. The postoperative client has complained of constant pain despite receiving pain medication several times.

Evaluate each option

Consider each possible action that the nurse may take. A. Call the doctor and ask for a change in the client's medication B. Perform a head-to-toe assessment C. Administer another dose of the client's prescribed analgesic D. Ask the client whether she is addicted to pain medications

Think about the nursing process

The nursing process generally consists of the following steps: assessment, diagnosis, planning, intervention, and evaluation. Remember that it is essential to assess the client's situation before taking any further action.

Decide the most appropriate action

Based on the importance of assessment in the nursing process, option B is the most appropriate action. Performing a head-to-toe assessment would allow the nurse to gather relevant information about the client's condition and potentially identify the cause of the ongoing pain. This information would guide the nurse in deciding the best course of care or whether to consult with the doctor for changes in medication. Answer: B. Perform a head-to-toe assessment