A nurse is caring for a client who had total hip arthroplasty 2 days ago. Which of the following actions should the nurse take

Rationale:

A. Instruct the client to remain on bed rest for the first 24 hr: Strict bed rest is not recommended after a laparoscopic cholecystectomy because early ambulation helps reduce the risk of atelectasis, venous thromboembolism, and postoperative gas pain. Keeping the client immobile can delay recovery and contribute to complications.

B. Instruct the client to consume foods high in fat: High-fat foods can trigger abdominal discomfort and diarrhea after gallbladder removal because bile secretion is no longer regulated. Clients are advised to begin with low-fat meals to prevent gastrointestinal distress while the body adjusts to continuous bile flow.

C. Instruct the client to cough and breathe deep every hour: Deep breathing and coughing exercises help prevent postoperative pulmonary complications, especially atelectasis from anesthesia and reduced mobility. Encouraging these exercises hourly promotes lung expansion, clears secretions, and supports optimal respiratory function during recovery.

D. Instruct the client to avoid taking a shower for 1 week: Most clients may shower within 24–48 hours after a laparoscopic procedure once dressings are removed, provided incisions are clean and dry. Restricting showers for an entire week is unnecessary and may hinder comfort and hygiene without providing additional protection to the incision sites.

Rationale:

A. Compare the current infusion with the prescription in the client's medication record: The first action is to verify the actual prescription against the current IV infusion. This ensures that the client is receiving the correct medication, dose, and rate, and allows the nurse to identify any errors or discrepancies before taking further action.

B. Submit a written warning for the nurse involved in the incident: Disciplinary action is not appropriate as an initial step. The priority is client safety and verifying facts, not assigning blame. Investigations or corrective actions follow after assessment and verification.

C. Complete an incident report and place it in the client's medical record: Incident reports are used to document discrepancies or errors, but they should not be placed in the medical record. They are submitted to risk management or quality assurance separately. Filing in the medical record could create legal and confidentiality issues.

D. Contact the charge nurse to see if the prescription was changed: While notifying the charge nurse may be necessary, it should occur after verifying the prescription and confirming the discrepancy. Immediate assessment and comparison to the medication record take priority to ensure client safety.