It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? A)Administer pain medication B)Call the health care provider to meet with the family to obtain informed consent C)Complete the preoperative checklist D)Perform the morning assessment

Question

Quizplus · Accepted Answer

The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option A) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option B) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option C) The preoperative checklist can be completed after consent is obtained. Educational objective: Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client's physiologic and psychologic status, and completes the preoperative checklist.

It Is 0700 and the Nurse Is Caring for an 84-Year-Old