A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Choice A reason: Clean gloves are necessary when touching or being in close proximity to any wound, especially one that is infected with MRSA. MRSA is a highly contagious bacterium that can spread through direct contact with the infected area or through indirect contact with contaminated objects. Wearing clean gloves helps prevent the transmission of MRSA to the nurse and to other patients.

Choice B reason: Protective eyewear is not typically required for checking a patient's pulse. However, if there is a risk of splashing or spraying of bodily fluids, protective eyewear becomes necessary to protect the mucous membranes of the eyes from exposure to infectious materials.

Choice C reason: Sterile gloves are used during procedures that require an aseptic technique, such as the changing of a sterile dressing or during invasive procedures. Checking a patient's pulse does not require sterile gloves, as it is not an aseptic procedure.

Choice D reason: A surgical mask should be worn if there is a risk of droplet transmission or if the nurse will be in close contact with the patient's wound. MRSA can be present in nasal secretions and can be spread by droplets, so wearing a mask can provide an additional layer of protection against the transmission of MRSA.

Choice A reason: The FACES pain scale is commonly used for children who are able to select a face that best describes their pain. However, this scale is not suitable for a 6-month-old infant post-myringotomy, as infants of this age cannot verbally communicate or reliably choose a face to represent their pain level.

Choice B reason: The Visual Analog Scale (VAS) is typically used for older children and adults who can understand and indicate their level of pain by marking a point on a line. This scale is not appropriate for infants due to their developmental stage and inability to communicate or understand the concept of the scale.

Choice C reason: The Oucher pain scale includes both a photographic scale with pictures of children's faces showing different levels of pain and a numerical scale. While it is designed for children aged 3 to 12 years, it is not suitable for infants, as they cannot verbally express their pain or point to a photograph to indicate their pain level.

Choice D reason: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is an appropriate choice for assessing pain in infants and young children who are non-verbal. It involves observing specific behaviors and assigning a score from 0 to 2 for each category, resulting in a total score between 0 and 10. This observational tool allows healthcare providers to assess pain levels based on the infant's behavior and physiological responses.