A nurse knows that the liver is a common site for metastasis from other primary cancers due to:

A. Urticaria (hives) is not a common side effect of radiation therapy. The skin should be examined for localized radiation-induced skin changes, such as erythema or dryness, rather than generalized urticaria.
B. Radiation therapy can weaken the immune system, increasing the risk of infection. The nurse should monitor for signs of infection, especially in areas affected by radiation, as the skin and mucous membranes can become more vulnerable.
C. Low hemoglobin is not a direct or immediate concern related to radiation therapy for lung cancer. However, it could occur if the patient experiences bone marrow suppression, but this is not typically the primary concern for radiation therapy to the lung.
D. Xerostomia (dry mouth) is more commonly associated with radiation therapy to the head and neck area. Radiation to the lungs generally does not affect salivary glands, so monitoring for xerostomia is not necessary in this case.

A. Hypoxia is common after surgery due to the effects of anesthesia and the client being in a supine position. A pulse oximetry reading of 88% indicates mild hypoxia. The first step in managing this is to encourage deep breathing or to have the patient use an incentive spirometer to improve ventilation and oxygenation. This is a non-invasive method that can help increase oxygen levels and prevent complications like atelectasis (lung collapse).

B. While opioid overdose can cause respiratory depression, there is no indication that the client is showing signs of opioid toxicity (e.g., unresponsiveness, slow/shallow breathing). The client is sleepy but easily arousable, suggesting that the sleepiness is related to the residual effects of anesthesia rather than opioid overdose. Administering naloxone is not indicated unless there are signs of severe respiratory depression or unresponsiveness, which is not the case here.

C. While postoperative hypothermia can occur, it is unlikely to cause oxygen saturation to drop to 88%. The priority action should be to improve the client's oxygenation first, as that is more immediately critical in this scenario.

D. The client's oxygen saturation of 88% is concerning, but it is manageable with initial interventions such as encouraging deep breathing. Calling a rapid response team would be appropriate if the patient's condition worsens or doesn't improve with initial interventions.