The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?

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: Administering pain medication as ordered is not the best action, as it does not address the cause of the new onset of pain. The nurse should first assess the client and the surgical site to rule out any complications or problems that may require immediate intervention.

Choice B reason: Assessing the client for signs and symptoms of systemic infection is not the best action, as it is not the most likely cause of the new onset of pain. Systemic infection would manifest with fever, chills, malaise, or leukocytosis, which are not mentioned in the scenario. The nurse should focus on the local signs and symptoms of the surgical site and the affected extremity.

Choice C reason: Assessing the surgical site and the affected extremity is the best action, as it allows the nurse to identify any potential complications or problems that may explain the new onset of pain. The nurse should look for signs of infection, inflammation, bleeding, hematoma, or dislocation of the hip prosthesis, such as redness, swelling, warmth, drainage, bruising, or deformity.

Choice D reason: Reassuring the client that pain is a direct result of increased activity is not the best action, as it may dismiss the client's concern and delay the detection of any serious complications or problems. The nurse should not assume that the pain is normal or expected, but rather investigate the cause and severity of the pain.

Choice E reason: Notifying the surgeon immediately is not the best action, as it is premature and unnecessary without first assessing the client and the surgical site. The nurse should gather relevant data and information before contacting the surgeon, unless there is an obvious or urgent problem that requires immediate attention.