During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following?

A. Monitoring the insertion site for infection: Infection is a potential complication, but it is not an immediate concern right after the procedure. Signs of infection develop hours to days later, so this assessment is important but not the priority in the immediate postprocedure period.

B. Checking for orthostatic hypotension: Orthostatic changes are not typically the most urgent issue immediately after cardiac catheterization. The client is usually kept in a supine position, which limits the risk of sudden blood pressure drops. While monitoring vital signs is important overall, vascular site integrity takes precedence at this stage.

C. Forcing fluids: Increasing fluid intake is encouraged postprocedure to promote excretion of contrast dye and protect kidney function. However, this intervention does not address the primary acute risk, which is bleeding from the catheter insertion site. Fluids are helpful but not the most immediate priority.

D. Immobilizing the affected extremity: The insertion site, often in the femoral artery, is at high risk for bleeding or hematoma formation immediately after the procedure. Immobilizing the extremity helps maintain pressure at the site and prevents disruption of the arterial puncture. This action directly reduces the risk of hemorrhage, making it the top priority.

A. Provide a flexible activity schedule: Clients experiencing acute mania often have high energy levels and may be unable to follow a flexible or self-directed schedule. Structured, brief, and supervised activities are more effective than a flexible schedule in managing behavior and ensuring safety.

B. Provide high-calorie nutritional supplements: Clients in acute mania may be too hyperactive or distracted to consume adequate meals. Offering high-calorie supplements helps prevent malnutrition and weight loss by providing concentrated nutrition in a format that is easier for the client to consume amidst hyperactivity.

C. Allow the client to eat meals alone in her room: Eating alone may increase the risk of inadequate intake because manic clients can be easily distracted or forget to eat. Supervised meals in a calm environment promote adequate nutrition and monitoring of intake.

D. Allow the client to choose her clothes independently: While promoting autonomy is generally important, clients in acute mania may select inappropriate or unsafe clothing due to impaired judgment. Providing guidance or limiting choices temporarily ensures safety and appropriateness of dress.