A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A. Serum sodium levels are typically assessed to evaluate electrolyte balance and hydration status. While important for overall health assessment, it is not specifically related to monitoring the effects of warfarin therapy.
B. This could be ordered for various reasons such as assessing lung status or identifying any abnormalities in the chest. It is not directly related to monitoring warfarin therapy.
C. BUN levels are measured to assess kidney function and hydration status. While important for overall health assessment, it is not specifically related to monitoring the effects of warfarin therapy.
D. The INR is a standardized measurement of the blood's ability to clot. Warfarin works by inhibiting vitamin K-dependent clotting factors, thereby prolonging the time it takes for blood to clot. The INR is used to monitor and adjust warfarin dosage to maintain therapeutic anticoagulation levels, especially in patients with conditions like atrial fibrillation who are at risk of blood clots.

A. Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D. Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E. Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.