A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?

B Medicate for pain and monitor vital signs according to protocol. D Administer intravenous fluid bolus as prescribed by the healthcare provider. A Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. C Encourage the client to splint the incision with a pillow to cough and deep breathe.