Level: Foundational
Difficulty: Easy
Subtopic: Pain assessment
NCLEX: A client rates pain 8/10 after abdominal surgery and guards the incision. What should the nurse do first?
Health assessment Reduction of Risk Potential
Case Study
A client rates pain 8/10 after abdominal surgery and guards the incision. What should the nurse do first?
Question
A. Assess pain location, quality, and vital signs, then intervene per protocol and notify the provider if needed.
B. Tell the client that some pain is expected and avoid medications to prevent dependence.
C. Document pain as 8/10 and reassess at the end of the shift.
D. Delegate pain assessment to UAP without RN follow-up.
B. Tell the client that some pain is expected and avoid medications to prevent dependence.
C. Document pain as 8/10 and reassess at the end of the shift.
D. Delegate pain assessment to UAP without RN follow-up.
Rationale
Correct answer: A. Assess pain location, quality, and vital signs, then intervene per protocol and notify the provider if needed.
Rationale: Severe pain requires timely RN assessment and intervention; delegation of assessment is inappropriate for acute postoperative pain.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Severe pain requires timely RN assessment and intervention; delegation of assessment is inappropriate for acute postoperative pain.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.