A nurse works on a postoperative care unit and sees many patients ...

[torybrooks]

A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery. One patient complains of significantly more pain than the other postoperative patients usually do. What action by the nurse is best?
 
  a. Explain to the patient that so much pain is not reasonable.
  b. Ask the patient to rate and describe the pain.
  c. Give the patient pain medications as prescribed.
  d. Call the provider and request an extra dose of pain medication.

Question 2

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
 
  a. Instruct the patient not to get up without help.
  b. Document the findings and continue to monitor.
  c. Reassure the patient that these findings are normal.
  d. Reassess the blood pressures in 1 hour.

[shailee]

Answer to Question 1

ANS: B
Pain is a subjective experience and patients' pain experiences will not all be the same. The nurse needs to assess the patient's pain further. After assessing the patient's pain, if it is time for a dose of pain medication, the nurse should administer it. If the nurse's clinical judgment indicates an additional dose of medication is warranted, the provider can be contacted. The nurse should not dismiss the patient's pain by telling him/her that it is unreasonable.

Answer to Question 2

ANS: A
This patient has orthostatic hypotension, which is a drop of 20 mm Hg in systolic reading and 10 mm Hg in diastolic reading when the patient stands up from a sitting or lying position. The patient's cardiovascular system does not compensate for this, so the patient is at risk of becoming dizzy and fainting. The nurse instructs the patient to call for assistance before getting up to prevent a fall. The nurse should document the findings but needs to do more. These findings are not normal, so the nurse should not tell the patient that they are. The patient may need to be assessed sooner than 1 hour.