The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Choice A reason: This is not the best intervention as it does not address the cause of the pain or provide adequate relief. Deep breathing may help the client to relax and cope with the pain, but it is not enough to manage severe pain.

Choice B reason: This is not a true or helpful statement as it may imply that the nurse is dismissing the client's pain or delaying further action. Oxycodone is a fast-acting opioid analgesic that reaches its peak effect within 30 to 60 minutes. If the client is still in severe pain after one hour, the nurse should reassess the pain and notify the healthcare provider.

Choice C reason: This is not the priority intervention as it does not address the cause of the pain or provide adequate relief. A backrub may help the client to relax and distract from the pain, but it is not enough to manage severe pain.

Choice D reason: This is the best intervention as it helps the nurse to evaluate the effectiveness of the medication and the need for further intervention. The nurse should use a valid and reliable pain assessment tool and ask the client about the location, intensity, quality, and duration of the pain. The nurse should also check the client's vital signs and observe for any signs of adverse effects from the medication.

Choice A reason: This is not the most important assessment because abdominal girth is not a reliable indicator of fecal impaction. Abdominal girth can vary depending on the client's body type, fluid status, and other factors.

Choice B reason: This is also not the most important assessment because breath sounds are not directly related to fecal impaction. Breath sounds can be affected by respiratory conditions, smoking, allergies, and other factors.

Choice C reason: This is another incorrect choice because bowel sounds are not the most important assessment either. Bowel sounds can be diminished or absent in clients with fecal impaction, but they can also be altered by other gastrointestinal disorders, medications, and dietary factors.

Choice D reason: This is the correct choice because vital signs are the most important assessment prior to initiating digital removal of a fecal impaction. Vital signs can indicate the client's hemodynamic status, pain level, and risk of complications such as vagal stimulation, perforation, or infection. The nurse should monitor the client's blood pressure, pulse, respirations, and temperature before, during, and after the procedure.