A nurse is caring for a patient who has just returned from the operating room after a major abdominal surgery. The nurse notices that the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, oxygen saturation is 92%, and urine output is 20 mL/h. What is the nurse's priority action?

Choice A reason:

This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.

Choice B reason:

This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.

Choice C reason:

This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.

Choice D reason:

This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.

Choice A reason:

This is not the best response because it does not address the patient's pain experience or offer any empathy. It also implies that medication is the only option for pain relief, which may not be true.

Choice B reason:

This is the best response because it acknowledges the patient's pain and asks them to elaborate on how it affects their daily activities. This can help the nurse assess the impact of pain on the patient's quality of life and plan appropriate interventions.

Choice C reason:

This is not the best response because it focuses on the duration and triggers of pain, which are more relevant for chronic pain than acute pain. It also does not show empathy or validate the patient's pain rating.

Choice D reason:

This is not the best response because it only expresses sympathy but does not ask the patient any questions or offer any solutions. It may also sound patronizing or dismissive to some patients.