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: The most appropriate intervention is to perform a head-to-toe assessment. This allows the nurse to gather crucial information about the client's condition, potentially identify contributing factors to the persistent pain, and determine the most appropriate course of action to address the client's needs.

Step-by-step solution

Analyze the client's situation

First, carefully read the information provided in the scenario. The client has recently undergone surgery and is experiencing unremitting pain. Despite being given pain medication several times, there appears to be no improvement in the client's condition.

Evaluate action A

Action A suggests calling the doctor and asking for a change in the client's medication. While this could potentially be a good course of action, it is important to gather more information about the client's situation and rule out other possible causes for the persistent pain before requesting a change in medication.

Evaluate action B

Action B suggests performing a head-to-toe assessment. This is an appropriate intervention as it allows the nurse to gather more data about the client's condition, identify possible causes for the persistent pain, and determine if any other complications or factors may be contributing to the issue. Also, in this circumstance, given that the medication is not having the desired effect, it is essential to reassess the patient's condition before attempting further interventions.

Evaluate action C

Action C suggests administering another dose of the client's prescribed analgesic. However, since the client has already been given pain medication several times without any relief, it is important to gather more information and reassess the situation before providing additional medication.

Evaluate action D

Action D suggests asking the client whether she is addicted to pain medications. While it may be relevant to know about the history of substance use, asking the patient about addiction is not an appropriate immediate action in this situation. The focus should be on addressing the client's pain and evaluating potential causes for the lack of relief.

Choose the best action

Based on the evaluation of each proposed action, action B (perform a head-to-toe assessment) is the most appropriate intervention at this time. This approach allows the nurse to gather crucial information about the client's condition, potentially identify contributing factors to the persistent pain, and determine the most appropriate course of action to address the client's needs.