Question

postoperative day 1:
client awake, sitting up in chair with eyes closed tightly, not speaking. spouse, friend, and parent at bedside. visitors conversing and laughing loudly with each other. television on with volume high. client begins to cry and states, \i tried to use the incentive spirometer, but it hurts to take a deep breath or cough.\
the client was last medicated for pain with hydromorphone 0.5 mg iv 6 hours ago. client offered pain medication. client states, \i want to wait until after the dressing change to have my pain medicine.\ clients spouse states, \that pain medicine you nurses are putting in the iv makes my spouse so dizzy and sleepy. im sure its addictive. cant you just give a pain pill?\

Explanation:

The client is in pain, but the spouse has concerns about the IV pain medication. Before medicating, the nurse should first assess the client's pain level using a standard pain scale. This helps in determining the appropriate pain management approach. Also, the noisy environment (visitors conversing and laughing loudly, television on high volume) can exacerbate the client's discomfort. However, the priority is to assess the pain level as it guides the subsequent actions (whether to medicate, what type of medication, etc.).

Answer:

determine the client's tolerable pain level using a standard pain scale