Question

Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV q6h.

Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His respirations are 32/min, compared to a baseline of 16/min. His O2 saturation is 85%. The nurse immediately calls for help. Which of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What were you doing before the pain began?"

Answer 1

The most important question for the nurse to ask is 'What were you doing before the pain began?' (option 4 is the correct answer)

Step-by-step explanation:

The most important question for the nurse to ask in this situation is 'What were you doing before the pain began?' This question is important because it will help determine if the patient's symptoms are related to an activity or event that could have caused a medical emergency. The other questions are also important, but they are less relevant to the immediate concern of assessing the patient's current condition.

Activity-related factors can provide crucial insights into the likelihood of thromboembolic events, given Mr. Palmer's recent surgery and immobilization. This information is vital for making rapid clinical decisions and initiating appropriate interventions. The other questions may be important for overall assessment but do not directly address the urgency of potentially life-threatening complications like PE or MI.

Prompt and focused assessment, particularly inquiring about recent activities, is crucial in situations of acute distress postoperatively. By asking about the patient's activities, the nurse aims to identify potential triggers for the symptoms and guide timely intervention to address possible complications like pulmonary embolism or myocardial infarction.