Questions: The nurse is gathering data from a client on the first day after a thoracotomy. The client has a temperature of 100 degrees F (37.8 degrees C); heart rate, 96 beats/minute; blood pressure, 136 / 86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases, and reports incisional pain. Which nursing action has priority? Help the client get out of bed. Medicate the client for pain. Encourage the client to cough and deep breathe. Give ibuprofen as ordered to reduce the fever.

The answer is: Encourage the client to cough and deep breathe.

Explanation for each option:

1. Help the client get out of bed: While mobilization is important for recovery after surgery, the immediate priority in this scenario is to address the respiratory status, as the client has shallow respirations and rhonchi, indicating potential respiratory complications.

2. Medicate the client for pain: Pain management is important, but in this case, the priority is to ensure adequate ventilation and prevent respiratory complications. Once the respiratory status is addressed, pain management can be considered.

3. Encourage the client to cough and deep breathe: This is the priority action. Coughing and deep breathing exercises help to expand the lungs, clear secretions, and improve oxygenation, which is crucial given the client's shallow respirations and presence of rhonchi.

4. Give ibuprofen as ordered to reduce the fever: While reducing fever can be beneficial, it is not the immediate priority. The client's respiratory status takes precedence due to the risk of complications such as atelectasis or pneumonia.

In summary, the priority nursing action is to encourage the client to cough and deep breathe to address the respiratory issues and prevent complications.