A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine.
The nurse determines pulses are faintly palpable and the foot is cool to the touch.
Which action should the nurse take next?

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.

Choice A rationale

Clamping the chest tube can cause increased pressure in the pleural space and is not appropriate without specific indications.

Choice B rationale

Increasing the wall suction may not relieve the burning sensation and could potentially cause harm.

Choice C rationale

Repositioning the client can help alleviate the burning sensation by adjusting the position of the chest tube and the lung.

Choice D rationale

Stripping the chest tube is not recommended as it can increase intrathoracic pressure and cause damage.