Question

"The day after a thoracotomy, a client experiencing incision pain has a temperature of 99°F (37.2°C); heart rate 96 beats/minute; blood pressure 136/86 mmHg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases and an oxygen saturation of 98%. Which nursing action is the priority?"

Answer 1

Answer: Pain Management and Monitoring for posible Infection or Difficulty Breathing

Step-by-step explanation:

The patient had surgery performed the day before. The increasing of blood pressure can be associated with pain, also the patient has shallow breathing with rhonchi sounds on the bases of the lungs, associated with a slight increase of body temperature. The patient should be observed more closely and monitored his body temperature for possible infection.

Answer 2

Administer analgesics and control body temperature.

Explanation:

The shallow respirations with rhonchi at the bases are due to the thoracotomy. The slightly elevated temperature might be a sign of infection, the patient's temperature should be controlled during the next 24 hours. If the temperature increases there is an infection. Feber is a result of the body fighting an infection. As regards the pressure, the patient seem s to be in a lot of pain, causing an increase in this one, painkillers should be given for this.