A nurse is providing teaching about self-care to a client who is primigravid and at 9 weeks of gestation. Which of the following statements should the nurse include?

A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.

B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.

C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.

D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.

A. A client who has an open fracture of the tibia and reports pain as 5 on a scale of 0 to 10: While the open fracture requires prompt attention to prevent infection and manage pain, it is not immediately life-threatening. This client can be treated after more critical, unstable patients.

B. A client who has suspected appendicitis and reports severe lower right abdominal pain: Suspected appendicitis is urgent but not immediately life-threatening unless complications like rupture occur. This client’s condition is lower priority compared to airway or breathing compromise.

C. A client who has a penetrating head wound and fixed pupils: Fixed pupils suggest a non-survivable brain injury. In a mass casualty or disaster triage situation, this client is considered expectant and would not receive immediate intervention.

D. A client who has flail chest and a respiratory rate of 32/min: Flail chest with increased respiratory rate indicates respiratory compromise and potential hypoxia, which is life-threatening. Airway and breathing take priority, so this client requires immediate intervention to stabilize breathing and prevent rapid deterioration.