nursing interventions

| December 11, 2015

. A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after one and a half hours, now reports severe incisional pain. The patient’s blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient’s skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to:

medicate the patient for pain.
place the patient in a high Fowler position and administer oxygen.
place the patient in a reverse Trendelenburg position and open the IV line.
report the findings to the provider.

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