A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

The client is at risk for developing constipation due to opioid use.

Rationale:

• Opioid Use → Constipation: Oxycodone, like other opioids, slows gastrointestinal motility, leading to constipation. This is a common postoperative concern, especially in clients with reduced mobility after a hip arthroplasty.

  • Confusion – No signs of mental status changes or factors like electrolyte imbalances.
  • Pressure Injuries – While immobility increases risk, this is not directly related to the provided findings.
  • Hypoglycemia – Blood glucose is normal, and there’s no IV dextrose mentioned.
  • Dysrhythmias – Potassium and sodium levels are within normal limits, reducing electrolyte-related cardiac risks.

A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.