A nurse is caring for a client who is postoperative following a cholecystectomy and reports incisional pain. Which of the following actions should the nurse take?

Choice A reason: Severe pain and nausea with impending vomiting are urgent, but respiratory depression from morphine (respirations 10 breaths/min) is life-threatening due to hypoxia risk. Vomiting can be managed with antiemetics after addressing opioid-induced respiratory compromise, making this patient less immediate.

Choice B reason: Post-surgical abdominal pain with writhing and moaning requires pain management, but it is not immediately life-threatening compared to morphine-induced respiratory depression. Addressing airway and breathing takes precedence, as pain can be treated after stabilizing vital signs, making this less urgent.

Choice C reason: The patient with respirations of 10 breaths/min after morphine is the priority, as opioid overdose can lead to respiratory arrest. Pulse (62 beats/min) and blood pressure (102/60 mmHg) suggest compromise, requiring immediate intervention (e.g., naloxone) to reverse hypoxia, making this the most critical patient.

Choice D reason: A pale, still patient with warm, dry skin but no pain may indicate shock, but no vital sign abnormalities are specified. Morphine-induced respiratory depression presents a more immediate, clear danger, as low respirations risk hypoxia, making this patient less urgent.

Choice A reason: Shallow breathing may indicate respiratory depression, a concern with opioids, but assessing pain intensity is the priority to determine the need for medication need. Pain level guides safe dosing, ensuring appropriate relief without overmedicating, making this a secondary assessment in acute pain.

Choice B reason: Blood pressure may rise with pain but is less specific than pain intensity for guiding medication administration. Pain level directly informs the need for and dose of analgesia, while blood pressure changes can have multiple causes, making this less critical.

Choice C reason

d): Assessing pain intensity level is the priority, as it quantifies the client’s subjective experience using a scale (e.g., 0-10 scale)), determining the need for and dose of pain medication. This ensures effective, patient-centered pain management, making it the most critical assessment before administering medication.

Choice D reason: Heart rate may increase with pain, but it is not the priority compared to pain intensity, which directly drives medication decisions. Heart rate changes are less specific and can result from other factors (e.g., anxiety), making this a secondary assessment in acute pain management.