medium · NCLEX-RN basic-care
The registered nurse is evaluating a 48-year-old male client who is on postoperative day 1 after a total hip arthroplasty. The client has a morphine patient-controlled analgesia (PCA) pump. The client reports a pain score of 8 out of 10. The nurse observes the client is currently ambulating down the hallway with physical therapy, conversing easily, and demonstrating steady gait.
Which action represents the most appropriate clinical judgment by the nurse?
- Complete a comprehensive functional pain assessment, evaluating how the pain limits physical activity, before adjusting the PCA.
- Document that the client is experiencing severe pain and administer a rescue dose of oral oxycodone as prescribed, for this client.
- Instruct the client to press the PCA demand button multiple times before beginning any future physical activity, for this client.
- Immediately contact the provider to request an increase in the PCA demand dose based on the reported pain score.
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