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?\
the nurse documents a nurses note. the nurse enters the clients room to
perform an assessment and change the clients abdominal dressing.
which 3 observations does the nurse address immediately?

1. visitors conversing and laughing loudly.
2. television turned on with volume high.
3. client crying and states, \it hurts to take a deep breath or cough.\
4. pain medication in the iv is making the client dizzy and sleepy.
5. client last medicated for pain 6 hours ago.
6. client states need to wait for pain medication until after dressing

change.

1. spouse concerned client will become addicted to pain

medication.

Explanation:

• Option 3: Client's pain (crying, pain on breathing/coughing) is a priority as it affects recovery (e.g., inability to deep - breathe/cough can lead to respiratory complications).
• Option 5: Last pain medication was 6 hours ago. Given the client's current pain, assessing for timely pain management (since hydromorphone IV has a relatively short half - life and postoperative pain typically requires more frequent dosing in the early period) is crucial.
• Option 6: Client delaying pain medication until after dressing change. Pain during dressing change can increase anxiety and pain perception, and adequate pre - medication can improve the client's experience and cooperation during the procedure.

Options 1 (loud visitors) and 2 (high TV volume) are environmental factors but not immediate threats to the client's physical well - being compared to pain. Option 4 (dizziness/sleepy from IV pain meds) is a side - effect but the client is not currently on IV pain meds (last was 6 hours ago). Option 7 (spouse's addiction concern) is an educational need but not an immediate physical assessment/management priority like the client's pain and pain - related decisions.

Answer:

1. Client crying and states, "It hurts to take a deep breath or cough."
2. Client last medicated for pain 6 hours ago.
3. Client states need to wait for pain medication until after dressing change.