54. During surgery, a client received spinal anesthesia 4 hours ago. The client reports severe incisional pain. BP is 90/70 mm Hg, P is 108, T is 99°F (37.2°C), and R is 30. The skin is pale. The dressing is dry and intact. The most appropriate nursing intervention is to:
. Call the physician and report the findings.
. Medicate the client for pain, as ordered.
. Reposition the client.
. Open the IV to run at a rapid rate.
Test-Taking Tip
Keep It Simple (K.I.S.)—This client is in pain → give medication for pain. Recognize the effects of pain on vital signs.
Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is incorrect because the client should be medicated first, and then if BP and pulse do not change, the physician should be contacted. Answer 2 is correct because the postoperative pain is most likely causing the vital sign changes. Answer 3 is incorrect because the only position that would improve the BP would be to elevate the legs, which would be contraindicated following spinal anesthesia. Answer 4 is incorrect because the problem is not hypovolemia.