A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?

a . Provide a tour of the perioperative area prior to surgery.

The correct answer is a. Provide a tour of the perioperative area prior to surgery.

Explanation:

When caring for an adolescent scheduled for surgery, providing a tour of the perioperative area prior to the procedure is an important action for the nurse to take. Adolescents may experience fear and anxiety related to the unfamiliar environment and procedures associated with surgery. Providing a tour allows the adolescent to become familiar with the surroundings, equipment, and healthcare team, which can help alleviate anxiety and promote a sense of control.

Explanation for the other options:

b. Explain that anesthesia is a special type of sleep: While it is important to provide information about anesthesia to the adolescent, describing it as a "special type of sleep" may be misleading. Anesthesia is a medical procedure that involves more than just being asleep, and it is important to provide accurate information to the adolescent.

c. Keep medical equipment out of the client's sight: While it is important to create a comfortable and non- threatening environment for the adolescent, completely hiding medical equipment may not be feasible or necessary. Instead, the nurse should address any specific fears or concerns the adolescent may have and provide age-appropriate explanations and reassurance.

d. Wait until after surgery to explain the importance of coughing and deep breathing: It is important to provide preoperative education to the adolescent to promote their understanding and cooperation. Explaining the importance of coughing and deep breathing before surgery helps the adolescent prepare and participate in their own recovery. Waiting until after surgery may result in missed opportunities for early postoperative interventions.

In summary, providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control.

The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.

Explanation for the other options:

b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.

c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.

d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.