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

Choice A reason: Urinary catheterization is a well-known risk factor for HAIs, particularly catheter-associated urinary tract infections (CAUTIs). The use of indwelling urinary catheters can introduce bacteria into the urinary tract and is associated with a significant proportion of HAIs.

Choice B reason: While malnutrition can affect the immune system and increase the risk of infections, it is not a direct cause of HAIs. Good nutritional status is important for wound healing and infection prevention, but it does not cause HAIs by itself.

Choice C reason: Having multiple caregivers can increase the risk of transmitting infections, especially if hand hygiene and other infection control practices are not consistently followed. However, it is not considered a direct cause of HAIs like urinary catheterization is.

Choice D reason: Chlorhexidine washes are actually used as a preventive measure against HAIs, particularly in reducing the risk of surgical site infections. They are not a cause of HAIs but rather part of the solution to prevent them.

The correct answer is c. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.

Choice A Reason:

Having the client perform range-of-motion exercises of the arm: This statement is incorrect because it assesses mobility rather than pain or swelling. Range-of-motion exercises are typically used to evaluate joint flexibility and muscle strength, not the effectiveness of pain relief measures.

Choice B Reason:

Inspecting the site for reduced swelling: This statement is incorrect because, while it checks for swelling, it does not directly measure pain relief. Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client's pain levels.

Choice C Reason:

Asking the client to rate the pain: This is the correct choice because it directly measures the client's perception of pain. Pain is a subjective experience, and the most accurate way to assess it is by asking the client to describe or rate their pain. This method allows the nurse to gauge the effectiveness of the cold compress in providing pain relief.

Choice D Reason:

Monitoring the client's pulse rate: This statement is incorrect because pulse rate is not a direct indicator of pain or swelling reduction. While pain can sometimes cause an increase in pulse rate, it is not a reliable or specific measure of pain relief. Pulse rate can be influenced by various factors, including stress, anxiety, and physical activity.