A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. This is correct because data validation involves verifying information before taking action. The nurse gathers subjective data from the patient (time of last dressing change) and objective data (drainage) before making a clinical decision.

B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. This is incorrect because the nurse has not validated whether the pain medication can be given early or if other interventions should be attempted first.

C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. This is incorrect because the nurse has not validated whether the leg cramps are due to low potassium. Leg cramps can result from multiple causes, including dehydration or circulatory issues. Lab values should be checked first.

D. The nurse elevates a leg cast when the patient reports decreased mobility. This is incorrect because decreased mobility does not necessarily indicate the need for elevation. Data validation should include assessing for swelling, circulation, and pain before making a decision.

A. A patient who had surgery two days ago and is learning how to change the dressing. This is incorrect because this patient is stable and requires routine education, which is not an immediate priority.

B. A patient who was admitted 30 minutes ago for chest pain. This is correct because chest pain can indicate a life-threatening condition such as myocardial infarction. The nurse should assess this patient immediately, monitoring for signs of cardiac compromise and initiating emergency interventions if necessary.

C. A patient who received pain medication 10 minutes ago. This is incorrect because this patient is already receiving treatment, and there is no indication of urgent distress requiring immediate intervention.

D. A patient who is being transferred to a long-term care facility this afternoon. This is incorrect because transfer preparation is not an urgent priority compared to an unstable or potentially critical patient.