Caring for a client who had an appendectomy 4 hours ago

The nurse is caring for a client who had an appendectomy 4 hours ago. which finding requires immediate action by the nurse

a. High pitched sound heard upon inspiration

b. Apical heart rate of 100 to 110 beats/mins

c. Redness and edema noted at the incision site

d. Pain rating of 8 on a scale of 1 to 10.

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