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.).

The correct answer is choice A. Transparent dressing.

Choice A rationale:

Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.

Choice B rationale:

Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.

Choice C rationale:

Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.

Choice D rationale:

Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.

The correct answer is: d. Left fifth intercostal space at the midclavicular line.

Choice A: Left fourth intercostal space at the sternal border

The fourth intercostal space at the sternal border is not the typical location for the Point of Maximal Impulse (PMI). This area is more commonly associated with the tricuspid valve auscultation point. The PMI is usually found more laterally and inferiorly.

Choice B: Left third intercostal space at the sternal border

The third intercostal space at the sternal border is also not the correct location for the PMI. This area is generally used for auscultating the pulmonic valve. The PMI is located further down and towards the midclavicular line.

Choice C: Left second intercostal space at the midclavicular line

The second intercostal space at the midclavicular line is typically where the aortic valve is auscultated. The PMI is not found this high up on the chest.

Choice D: Left fifth intercostal space at the midclavicular line

This is the correct location for palpating the Point of Maximal Impulse (PMI). The PMI is usually located at the apex of the heart, which is found at the left fifth intercostal space along the midclavicular line. This is where the left ventricle is closest to the chest wall and can be felt most strongly during systole.