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: When a patient has an elevated temperature, the body is attempting to cool down through vasodilation, which is why the skin may appear flushed and feel warm. Removing excess blankets can help facilitate the body's natural cooling process. Offering fluids is also crucial as fever can lead to dehydration, especially if there is sweating. Adequate hydration helps regulate body temperature and replaces fluids lost through sweating. The normal body temperature range is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). When the body temperature rises above this range, interventions such as removing blankets and providing fluids can be effective in reducing fever.

Choice B reason: Increasing the patient's activity is not advisable when they have an elevated temperature and are experiencing severe fatigue. Activity generates heat and can raise body temperature further, exacerbating the fever. Rest is recommended to conserve energy and reduce metabolic demand, which can help lower the body temperature.

Choice C reason: The use of ice bags can be a rapid cooling measure but must be used with caution. Direct application of ice to the skin can cause vasoconstriction and shivering, which can actually increase the body's core temperature. It is generally reserved for hyperthermia or heatstroke when immediate cooling is necessary. For a simple fever, less aggressive cooling measures are usually preferred.

Choice D reason: Decreasing the patient's intake is not appropriate unless there is a specific contraindication, such as vomiting or risk of aspiration. Adequate nutrition supports the immune system and provides the energy needed for the body to combat the underlying cause of the fever.

Choice A reason: Wearing gloves when measuring a client's blood pressure is not typically necessary unless there is a risk of exposure to bodily fluids or if the client has an infectious disease. The use of gloves is based on the type of contact and potential for exposure, not routine tasks like BP measurement.

Choice B reason: Wearing gloves for all client contact is not necessary and is not consistent with standard precautions. Gloves should be used when there is potential contact with blood, body fluids, secretions, excretions, contaminated items, or mucous membranes.

Choice C reason: Gloves are not a substitute for hand hygiene. The primary reason for wearing gloves is to provide a barrier against infection, not to reduce handwashing. Hand hygiene is still required before donning gloves and after removing them, regardless of whether the gloves are soiled or not.

Choice D reason: Wearing gloves and a gown when bathing a client with open skin lesions is correct because it protects both the healthcare worker and the client from the risk of infection. Open skin lesions can be a source of infection, and PPE is necessary to prevent the transmission of pathogens.