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. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide baseline information about the client's cardiovascular and respiratory status. This assessment helps predict how well the client might tolerate the surgical procedure under anesthesia and monitor for any deviations during the procedure.
B. Establishing baseline vital signs before surgery provides a comparison point for monitoring the client's recovery and identifying any postoperative complications. Changes in vital signs postoperatively can indicate potential issues such as bleeding, fluid imbalance, or respiratory compromise.
C. Monitoring blood pressure before surgery helps identify clients at risk for intraoperative hypotension, particularly important during induction of anesthesia and throughout the surgical procedure. Establishing baseline blood pressure levels guides intraoperative management to maintain hemodynamic stability.
D. While vital signs are important for assessing physiological status, they do not directly assess pain. Pain assessment involves asking the client about their pain experience, location, intensity, and factors that alleviate or exacerbate pain. Vital signs can indirectly reflect pain if pain causes changes in heart rate or blood pressure, but they are not specific indicators of pain.

A. Completing an incident report may be necessary if the refusal could potentially impact patient care or if there are policies or procedures in place that require documenting such incidents. It helps to document the details of the refusal and any subsequent actions taken.
B. If the AP refuses to take the specimen, the nurse may need to take responsibility for ensuring the specimen is delivered to the laboratory promptly. This ensures that patient care activities are not delayed and that necessary diagnostic tests are performed in a timely manner.
C. Reporting the refusal to the charge nurse or supervisor is appropriate, especially if there are concerns about the AP's behavior or if it is part of the facility's policy to escalate such incidents. The charge nurse can then address the situation and determine the appropriate course of action.

D. Communicating with the AP to understand their concerns is essential. It allows the nurse to clarify any misunderstandings, address any issues or barriers the AP may have, and potentially resolve the situation collaboratively. It's important to listen to the AP's perspective and provide clarification or reassurance if needed.