A nurse is performing an assessment on a client receiving intravenous (IV) normal saline. The client reports discomfort and swelling at the (IV) site. The nurse needs to take appropriate actions to address the issue and prevent complications.

What condition might the nurse suspect based on the client's symptoms?

Choice A reason: Blood pressure 118/70 is normal, indicating stable hemodynamics. Pain (6/10) is more urgent, as uncontrolled pain increases stress hormones, impairing healing and risking complications like atelectasis, making blood pressure a lower priority in this postoperative scenario.

Choice B reason: Pain severity of 6/10 is a priority, as moderate postoperative pain increases catecholamine release, impairing healing and raising risks of complications like atelectasis or hypertension. Prompt pain management improves recovery, preventing physiological stress, making this the most urgent issue to address.

Choice C reason: Anxiety when family arrives is psychosocial but less urgent than pain (6/10). Pain causes physiological stress, increasing risks like impaired healing or respiratory complications, while anxiety’s impact is less immediate, making it secondary to effective pain management.

Choice D reason: Requesting pain medication information indicates a need for education but is less urgent than addressing pain (6/10). Uncontrolled pain risks physiological complications like increased heart rate or poor healing, making pain management the priority over providing medication information.

Choice A reason: Wheezes are high-pitched, musical sounds caused by narrowed airways, common in asthma or COPD exacerbations. They do not clear with coughing and are not moist or rumbling, making this an incorrect description for the lung sounds heard, which improve after coughing in this COPD client.

Choice B reason: Rhonchi are low-pitched, moist, rumbling sounds caused by secretions in larger airways, often in COPD. They improve with coughing as secretions are mobilized, matching the description provided. This makes rhonchi the accurate term for documenting these lung sounds, reflecting secretion accumulation in COPD.

Choice C reason: Crackles are fine or coarse popping sounds caused by fluid in smaller airways or alveoli, often in pneumonia or heart failure. They do not clear with coughing and are not rumbling, making crackles an incorrect choice for the moist, rumbling sounds that improve after coughing.

Choice D reason: Pleural friction rub is a grating sound caused by inflamed pleural surfaces, often in pleurisy. It is not moist or rumbling and does not improve with coughing, making it an inappropriate description for the lung sounds heard in this client with COPD, which are secretion-related.