3 FL OZ =

A. Distractions such as music. Music and other distractions, such as guided imagery or television, can help shift the patient's focus away from pain, reducing discomfort and anxiety.
B. Massage. Gentle massage can help promote relaxation, improve circulation, and reduce muscle tension, which may enhance pain relief when used alongside medication.
C. Cold or heat applications. Cold therapy can help reduce inflammation and swelling, while heat therapy can improve blood flow and relax muscles, making them effective in managing arthritis pain and post-surgical discomfort.
D. Vigorous rubbing of the joints. Vigorous rubbing could worsen pain and cause irritation, particularly in a patient with arthritis and post-surgical pain. Gentle approaches are more appropriate.
E. Relaxation techniques. Deep breathing, guided imagery, and progressive muscle relaxation can help lower stress and enhance the body's ability to manage pain.

A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.