A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action?

Question

Quizplus · Accepted Answer

The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing (Option C). Interrupting the sterile dressing change for a client with an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change were lengthy, the nurse could delegate the task of medicating the postoperative client to another nurse (Option D). (Option A) Although taking vital signs when a client reports pain is appropriate, evidence indicates that vital signs are unreliable physiologic indicators for pain. (Option B) The UAP is instructed to ask the client if they are having pain and then report back to the nurse. However, the registered nurse is responsible for pain assessment and should not delegate this task to the UAP. Educational objective: A nurse can prioritize client needs and problems according to the degree of threat to the client's survival and the potential for complications. The nurse uses clinical judgment to decide which client situation requires immediate attention and which one can wait.

A Nurse Is Changing a Sterile Dressing for a Client