The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

A. Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread to others. It addresses the immediate health concern and helps prevent further transmission.

B. While partners without symptoms may not show signs of infection, they could still be carriers of gonorrhea and should be tested and treated if necessary.

C. While using safe sex practices can reduce the risk of STIs, it may not completely eliminate the risk, especially if a partner has multiple sexual partners.

D. While sexual intercourse is a common mode of transmission for STIs, not all STIs are transmitted exclusively through sexual intercourse.

A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.

B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.

C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.

D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.