Which of the following interventions would be a priority when providing care to a client recovering from thoracic injuries sustained from a motor vehicle accident?
1. Monitor urine output
2. Assess vital signs
3. Assist to deep breath and cough every two hours
4. Perform passive range of motion to all extremities
3. Assist to deep breath and cough every two hours
Rationale:
The client has thoracic injuries and might be reluctant to deep breath and cough because of pain. The nurse needs to ensure that the client breaths deeply and coughs every two hours to mobilize secretions and prevent respiratory complications. Monitoring urine output and assessing vital signs are important but not the priority at this time. The client may be able to perform active range of motion for all extremities, so this intervention may or may not be indicated.
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