The nurse is turning a patient with a total hip replacement. Which of the following is the appropriate intervention?

Choice A reason: Oranges have minimal vitamin K, which does not significantly affect warfarin’s anticoagulant effect. They are safe for consumption, making this an incorrect food to avoid.

Choice B reason: Spinach is high in vitamin K, which counteracts warfarin by promoting clotting factor synthesis. Clients should limit such foods to maintain stable anticoagulation, making this the correct choice.

Choice C reason: Chicken breast is low in vitamin K and does not interfere with warfarin. It is a safe protein source, making it incorrect to include in foods to avoid.

Choice D reason: White bread contains negligible vitamin K, having no significant impact on warfarin efficacy. It is safe for consumption, making it incorrect for the teaching.

Choice A reason: Observing the cardiac monitor for an increased heart rate can suggest pain but is not specific, as tachycardia may result from anxiety or hypovolemia. Directly assessing the patient’s reported pain level using a standardized scale provides precise, subjective data to guide analgesia, making this a less priority.

Choice B reason: Asking the patient to rate their pain level is the priority, as it a quantifies their subjective experience (e.g., 0-10 scale), guiding pain management decisions. This patient-centered approach ensures timely, tailored intervention, addressing the complaint directly and informing subsequent actions like inspection or medication administration, making it the most critical step.

Choice C reason: Assessing body language offers nonverbal pain cues, but it is less reliable than a verbal pain rating. Nonverbal signs can be misinterpreted, and cultural factors may influence expression, making this a secondary assessment. Subjective pain rating provides clearer, actionable data, prioritizing it over observational cues.

Choice D reason: Inspecting the incision site is important for detecting complications (e.g., infection, dehiscence), but pain assessment precedes it. A patient’s reported pain level determines the urgency of further evaluation or intervention, making inspection a follow-up action rather than the initial priority when addressing postoperative pain complaints.