Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby. Select all the options that need to be reported to the responsible nurse.

Mr. Milby states his pain level is a 0/10

Head of bed is elevated 45 degrees

Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion.

all side rails on Mr. Milby's bed are down

the knee dressing is loose and not adhering on all sides

the machine is set to 45 degrees of flexion