A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Choice A reason: Checking the patient's temperature is important for assessing the severity of the pneumonia and monitoring for fever, but it is not the priority action before administering the first dose of vancomycin.

Choice B reason: Obtaining sputum cultures is the priority action because it allows for the identification of the causative organism and determination of its antibiotic susceptibility. This helps ensure that the prescribed antibiotic is appropriate for the patient's infection. Cultures should be obtained before starting antibiotic therapy to avoid interference with culture results.

Choice C reason: Checking the patient's blood pressure is important for overall patient assessment and monitoring, especially considering potential side effects of vancomycin. However, it is not the primary action needed before the first dose of the antibiotic.

Choice D reason: Drawing a blood specimen to evaluate the white blood cell count is useful for assessing the severity of the infection and the patient's immune response. However, this can be done after obtaining the sputum cultures and is not the immediate priority before administering the antibiotic.

Choice A reason: Teaching the patient to use guided imagery can be an effective pain management strategy, but it might not be the most immediate and reassuring intervention for a patient experiencing fear about postoperative pain. This approach is more useful as an additional technique rather than the primary intervention.

Choice B reason: Describing the type of pain expected with the patient's particular surgery can provide some insight into what to anticipate, but it does not necessarily alleviate fear or provide concrete strategies for managing pain. It might even increase anxiety by focusing on the details of the pain itself.

Choice C reason: Explaining the pain management plan, including the use of a pain rating scale, is the most effective intervention. This approach directly addresses the patient's concerns by providing them with a clear understanding of how their pain will be managed and controlled postoperatively. Knowing that there is a structured plan in place, with specific methods to assess and manage pain, helps build confidence and reduces fear. The use of a pain rating scale also empowers the patient to communicate their pain levels effectively, ensuring timely and appropriate interventions.

Choice D reason: Informing the patient that pain medication will be available is helpful, but it lacks the detail and comprehensive approach of explaining the entire pain management plan. Patients may still have concerns about how their pain will be assessed and addressed specifically.