A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

Choice A rationale:

This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.

Choice B rationale:

This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.

Choice C rationale:

This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.

Choice D rationale:

This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.

Choice E rationale:

This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.