The nurse is caring for a drowsy patient after surgery. Vital signs are pulse 112 beats/min, 16 breaths/min, SpO2 88% on room air, and blood pressure 145/88 mm Hg. Which nursing intervention is the priority for this patient?
Pain related to tissue damage
Risk for surgical site infection related to the surgical wound
Ineffective airway clearance related to ineffective cough
Deficient fluid volume related to blood and fluid loss