Patient Data

Exhibits

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Choice A: Request a family member to remain with the client is not the best intervention because it may compromise the confidentiality and accuracy of the assessment. The family member may not be able to translate correctly or may influence the client’s responses.
Choice B: Ask for the support of one of the client’s friends is not the best intervention because it may also violate the privacy and validity of the assessment. The friend may not be qualified or willing to translate or may have a conflict of interest with the client.
Choice C: Use drawings that are universal for all cultures is not the best intervention because it may not be sufficient or appropriate for the assessment. Drawings may not convey all the information needed or may be misinterpreted by the client.
Choice D: Obtain a staff member who is a bilingual interpreter is the best intervention because it facilitates the communication and understanding between the nurse and the client. The interpreter should be trained and certified in medical terminology and cultural sensitivity.

Choice A: Lead the client in guided imagery

This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.

Choice B: Give a dose of 2.5 mg of Morphine

This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.

Choice C: Assist the client to walk around the room

This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.

Choice D: Assess for sources of pain other than the surgical site

This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.

Choice E: Consult with the surgeon about the pain level

This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.