When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Choice A rationale: Potassium 3.5 mEq/L and sodium 142 mEq/L are within normal ranges, not expected after vomiting and diarrhea which typically cause hypokalemia and hypernatremia due to fluid loss.

Choice B rationale: Potassium 4.5 mEq/L and sodium 140 mEq/L remain normal, not consistent with dehydration and gastrointestinal fluid loss, which usually lower potassium and elevate sodium concentration.

Choice C rationale: Potassium 5.0 mEq/L and sodium 138 mEq/L are normal values, not typical after prolonged vomiting and diarrhea, where potassium decreases and sodium increases due to water deficit.

Choice D rationale: Potassium 3.0 mEq/L indicates hypokalemia from gastrointestinal losses, and sodium 149 mEq/L indicates hypernatremia from dehydration, both expected findings after vomiting and diarrhea.

This postoperative nursing scenario requires the application of non-pharmacological pain management strategies and safety protocols. Knowledge of gate control theory and surgical contraindications is essential to address breakthrough pain effectively while awaiting provider orders without compromising the integrity of the surgical site.

Choice A rationale: While massage can be soothing, 20 minutes of back massage and effleurage is physically demanding and may not be feasible in an acute care setting. Additionally, positioning a thoracic surgery client for a back massage might cause more incisional discomfort.

Choice B rationale: Guided imagery and slow rhythmic breathing are effective non-pharmacological interventions that reduce the perception of pain by decreasing autonomic nervous system arousal. These techniques empower the client and provide immediate relief without risk of injury to the incision.

Choice C rationale: Applying heat to a fresh surgical site is contraindicated because it increases vasodilation, which can lead to increased edema, bleeding, and potential incision dehiscence. Thermal devices should never be placed directly over a fresh operative site without specific orders.

Choice D rationale: Distraction through television or music can be a helpful adjunct, but it is often less effective than active cognitive-behavioral strategies like guided imagery for a pain level of 5. It serves as a passive intervention rather than an active coping skill.