A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

Rationale:

A. "Discontinue opioids before trying nonpharmacological methods of pain relief."
Nonpharmacological methods should complement, not replace, opioids. It's important to continue prescribed medications and incorporate nonpharmacological techniques to manage chronic pain.

B. "Distraction changes the client's perception of pain, but it does not affect the cause."
Distraction techniques, like listening to music, can alter pain perception by redirecting attention, but they do not address the underlying cause of pain.

C. "Use imagery with clients who have difficulty with focus and concentration." Imagery is a relaxation technique that requires focus. It may not be effective for clients with concentration difficulties, as they may struggle to benefit from this method.

D. "Pain relief from the use of heat and cold continues for several hours after removal of the stimulus." Pain relief from heat and cold is temporary and typically fades once the stimulus is removed. It provides short-term relief and should not be expected to last long after application.

Rationale:

A. Blood glucose level: The blood glucose level of 103 mg/dL is within normal limits (74 to 106 mg/dL) and does not require immediate follow-up. While the client has type 2 diabetes mellitus, the blood glucose is not abnormal at this time.

B. Bowel sounds: Bowel sounds are present in all four quadrants and do not require immediate follow-up. This finding is normal and is unrelated to the acute symptoms being assessed for a possible myocardial infarction.

C. Blood pressure: The client’s blood pressure is elevated at 164/80 mm Hg, which requires immediate attention in the context of chest pain and other symptoms that may suggest an acute myocardial infarction (MI).

D. Pain level: The client rates their chest pain as 7 out of 10, which is significant and consistent with potential myocardial ischemia or infarction. The pain’s radiation to the left arm, along with other symptoms like nausea and diaphoresis, suggest an urgent need for intervention.

E. Electrocardiogram findings: The 12-lead ECG shows tachycardia, ST segment elevation, and T wave changes, which are indicative of acute myocardial injury, such as an ST-elevation myocardial infarction (STEMI). This requires immediate intervention to prevent further myocardial damage.

F. Lung sounds: The lung sounds are clear in all lobes, which is reassuring and does not indicate an immediate concern.

G. Troponin T level: The elevated Troponin T level (0.40 ng/mL) is a key biomarker for myocardial injury. The elevation indicates ongoing cardiac damage, which requires immediate follow-up to assess for the extent of the infarction and initiate treatment.