The medical-surgical nurse is caring for a client postoperatively after a total hip arthroplasty. The nurse is calculating the client's intake and output and notes a total of 100 mL of sanguineous drainage out of the hip drain in the 24 hours since surgery. What is the most appropriate action for the nurse to take?

Choice A reason: Transferring from sitting to standing position is not a high-risk activity for hip dislocation, as long as the client follows the proper precautions, such as keeping the operated leg slightly forward, using a chair with armrests, and avoiding twisting or pivoting the hip.

Choice B reason: Straining during a bowel movement is not a direct risk factor for hip dislocation, but it may cause constipation, which is a common problem after surgery. The nurse should educate the client on the importance of adequate hydration, fiber intake, and stool softeners to prevent constipation and reduce the need for straining.

Choice C reason: Bending down to put socks on is a risky activity for hip dislocation, as it violates the hip precautions of avoiding flexing the hip more than 90 degrees, adducting the hip, or internally rotating the hip. The nurse should instruct the client to use assistive devices, such as a sock aid or a long-handled reacher, to put on socks or shoes without bending the hip.

Choice D reason: Turning in bed with an abductor pillow in place is a safe activity for hip dislocation, as the abductor pillow helps to maintain the alignment and stability of the hip joint. The nurse should teach the client to use the abductor pillow while in bed for the first few weeks after surgery, and to turn from side to side with the assistance of a caregiver.

Choice E reason: Crossing the legs or ankles is a dangerous activity for hip dislocation, as it causes the hip to move out of its normal position. The nurse should remind the client to keep the legs apart at all times, and to use a pillow or a wedge between the legs when lying on the side.

Choice A reason: Performing a neurovascular assessment of the extremity daily is not enough. The nurse should perform this assessment every 2 to 4 hours to monitor for signs of impaired circulation or nerve function.

Choice B reason: Assessing the client's skin condition under the boot weekly is not enough. The nurse should assess the skin under the boot at least once a day to prevent skin breakdown and infection.

Choice C reason: Increasing the traction if the client complains of increased pain is not appropriate. The nurse should not adjust the traction without a provider's order. Increasing the traction could cause more damage to the fracture site or the surrounding tissues.

Choice D reason: Ensuring that the traction weights do not touch the floor is the correct action. The nurse should make sure that the weights are hanging freely and not resting on anything. This ensures that the traction is applied continuously and evenly.