The nurse assesses the following on a client who had a colon resection 5 days ago: I & O × 4, skin warm, abdomen distended nontender, bowel sounds present. Abdominal sutures well approximated. States...

The nurse assesses the following on a client who had a colon resection 5 days ago: I & O × 4, skin warm, abdomen distended nontender, bowel sounds present. Abdominal sutures well approximated. States pain level 2 out of 10 on the pain scale. IV infusing at 75 mL/hr per pump. Fine crackles in the bilateral lower lung bases. In planning care, which nursing action is of priority?

a. Take vital signs q4h

b. Ambulate the client

c. Assess lung sounds q4h

d. Push oral fluids

 Rationale: