A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

To maintain skin integrity and decrease the risk of infection, it is important to keep the skin clean and well lubricated1. Using a moisturizer on your skin after cleaning can help to maximize lipid barriers and prevent dryness2. It is also important to avoid hot water during bathing as it can increase dryness and cause cracked skin2.

Answer: D. The client grimaces when they move.

Rationale:

A) The client rates their pain as an 8 on a scale of 0 to 10:

Pain ratings provided by the client are subjective and reflect their personal experience and perception of pain. While important for assessing pain severity, this rating is based on the client's personal report rather than observable evidence.

B) The client states the pain is located on their abdomen:

The location of pain, as reported by the client, is subjective information. It is based on the client's personal experience and cannot be objectively measured or observed by the nurse.

C) The client reports a burning sensation:

Describing the sensation of pain, such as a burning feeling, is a subjective experience. This description provides valuable information about the nature of the pain but does not serve as an objective indicator.

D) The client grimaces when they move:

Observing a grimace is an objective indicator of pain. It is a visible, physical response that the nurse can see and document, indicating that the client is experiencing discomfort or pain. Objective indicators are observable signs that can be noted by healthcare providers.