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A client on the first day after abdominal surgery ranks his pain as 9 on a scale of 0 to 10, 0 being no pain and 10 being the most pain possible. He is laughing and talking with visitors at this time. The client has defined a pain level of 5 as his comfort level goal. He has an order for analgesics every 1 to 2 hours. His last dose was the maximum ordered 2 hours ago. He had no untoward effects. The nurse should do which of the following?

1. Record his pain level at 5
2. Administer the maximum dose of the analgesic
3. Administer half the maximum dose of the analgesic
4. Take his vital signs in 30 minutes

Explanation

Always believe the client's report and ranking of pain. The client tolerated the last full dose of medication so he should be given a full dose now. The nurse would reassess the client's pain level within 30 minutes of administering pain medication depending on peak action time of the drug. The nurse would not need to take vital signs unless indicated. Omit options 1 and 4 as they do not address the client’s complaint of pain. Option 3 is not appropriate as the client’s self assessment of his pain level is high.

Contributor

Andrew
Member since: April 2011
(Boynton Beach,FL) Original question source

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