A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?

The correct answer is choice A. Use a communication board to interact with the client.

A communication board is a tool that allows the client to point to words, pictures, or symbols that express their needs, feelings, or pain level.

This is an effective way to communicate with a client who speaks a different language than the nurse and is unable to verbalize their pain.

Choice B is wrong because an assistive personnel who speaks the same language as the client is not a qualified interpreter and may not be able to convey the client’s pain accurately or maintain confidentiality.

Choice C is wrong because the FLACC scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.

It is not appropriate for a client who is 6 hours postoperative and can communicate their pain using a communication board.

Choice D is wrong because the FACES pain scale is a self-report measure of pain intensity developed for children.

It uses facial expressions to rate the severity of pain in children from 0-103.

It is not suitable for a client who speaks a different language than the nurse and may not understand the meaning of the faces.

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.