The nurse is caring for a client in the post anesthesia care unit…
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a
thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140
breaths/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHG.
Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Administer intravenous fluid bolus as prescribed by the healthcare provider
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter
d. Encourage the client to splint the incision with a pillow to cough and deep breathe