A nurse is assisting in the care of a newly admitted client.

Which of the following findings should the nurse report immediately to the provider? Select all that apply

A) You should avoid exercising for the next 6 weeks:
This statement is not accurate. The client is encouraged to gradually increase activity and participate in physical therapy as prescribed to improve mobility and strength following a total hip arthroplasty. While some rest and limited activity may be necessary immediately after surgery, complete avoidance of exercise for six weeks is generally not advised unless there are complications. Physical therapy exercises are often a key component in the recovery process after hip replacement surgery.

B) You should avoid lying on your right side:
This recommendation is incorrect unless specifically contraindicated due to complications. After a right total hip arthroplasty, the client can typically lie on either side once they are comfortable, unless instructed otherwise by the healthcare provider. It is important to follow the surgical instructions regarding positioning, especially avoiding positions that might place stress on the new joint

C) You should avoid putting a pillow between your legs when in bed:
This statement is incorrect. After a total hip arthroplasty, placing a pillow between the legs when lying on either side is recommended to maintain proper alignment of the hip joint and prevent dislocation. The pillow helps keep the legs slightly apart, preventing the hip from rotating inward, which can put the new joint at risk for dislocation.

D) You should avoid crossing your legs formonths:
This is correct. Following a total hip arthroplasty, it is essential to avoid crossing the legs, especially for the first several months. Crossing the legs can lead to hip dislocation or improper alignment of the joint. The nurse should reinforce the importance of avoiding crossing the legs both while sitting and lying down to ensure proper healing and to avoid complications such as dislocation of the new hip joint.

A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.

B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.

C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.

D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.