Question

After the nurse reports the findings to the HCP, Claudine is scheduled for immediate surgery. Following surgery, Claudine returns to her room. During the nursing assessment on the first postoperative day, Claudine seems anxious and tells the nurse that she hurts a lot.

In response to the client's statement that she hurts a lot, what action should the nurse take first?

- Explain to the client that post-operative pain is normal.
- Ask the client to describe her pain location and intensity.
- Ask the client if she has passed gas since surgery.
- Assess the client's heart rate and blood pressure.

Answer 1

The nurse's first action should be to ask Claudine to describe her pain location and intensity, as understanding the nature and intensity of pain is vital for effective pain management and for identifying potential complications early in the postoperative period.

Step-by-step explanation:

In response to Claudine's statement that she hurts a lot, the first action the nurse should take is to ask the client to describe her pain location and intensity. This initial step is crucial for assessing the patient's pain objectively and determining the best course of action for pain management. Adequate pain control postoperatively is not only essential for patient comfort but also for promoting recovery and preventing complications.

Understanding the nature, location, and intensity of pain can help healthcare providers to identify normal postoperative pain or recognize potential complications early. For example, very intense pain could potentially signify an issue such as an infection or a blood clot, and would need to be investigated and managed promptly.

Once the nurse has a better understanding of the pain Claudine is experiencing, they can then take appropriate steps such as administering prescribed analgesia, repositioning the client, or notifying the healthcare provider for further interventions.