A male client who weighs 90 kg is admitted to the emergency department with full thickness burns to 45% of his total body surface area (TBSA). The burns occurred at 1000. At 1200, the nurse uses the prescribed protocol for burns fluid resuscitation to calculate the total fluid volume for the first 24 hours. The infusion pump should be set to deliver how many mL/hour during the first 8 hours? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

A. Observe insertion site: The nurse should assess the suprapubic catheter insertion site for signs of infection, redness, or other complications. This is crucial to ensure the catheter is functioning correctly and to prevent infection.

B. Assess perineal area: The perineal area is not directly related to the suprapubic catheter, as it is inserted into the bladder through the abdomen. The focus should be on the insertion site and the catheter itself.

C. Measure abdominal girth: While measuring abdominal girth could be important if the client has issues such as fluid retention or urinary retention, it is not the primary focus for routine assessment of a suprapubic catheter.

D. Palpate flank area: The flank area may be relevant for kidney assessment, but for a suprapubic catheter, the primary focus should be on the catheter insertion site and its function.

A. Oxygen saturation 95% on room air A SpO2 of 95% is within acceptable limits, especially in a client who is not exhibiting signs of respiratory distress. This does not require immediate investigation, as it is not low enough to be concerning.

B. Bone misalignment: The client’s collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation that needs to be evaluated further to prevent further injury, ensure proper alignment, and determine the need for stabilization or surgical intervention.

C. Swelling at the site of injury: Swelling at the injury site, especially with a history of trauma, could indicate a fracture or soft tissue damage. The nurse should assess the extent of the swelling to rule out internal bleeding, compartment syndrome, or a fracture requiring urgent management.

D. Nausea and fatigue reported by client: Nausea and fatigue can be symptoms of more serious conditions, such as a concussion or internal bleeding, especially given the trauma to the head. These symptoms should be investigated to rule out any neurological or systemic involvement.

E. Decreased range of motion: The client’s decreased range of motion in the left arm, particularly with the reported intense pain, indicates a potential fracture, dislocation, or significant soft tissue injury. This needs to be further assessed to ensure proper treatment and avoid further complications.

F. Intense pain reported by client: The client reports intense pain (10 on a 0 to 10 scale) in the left arm, along with difficulty moving it. This is a critical symptom, suggesting a possible fracture, dislocation, or soft tissue injury that needs to be addressed immediately.

G. Left arm that is cool to touch: Coolness to the touch in the left arm could indicate a lack of adequate blood circulation, potentially from vascular injury or compression. This requires further evaluation to assess for possible arterial injury or compartment syndrome.

G. Blood pressure of 136/90 mm Hg: While 136/90 mm Hg is elevated for a general population, it is not an immediate life-threatening concern in this acute trauma setting. It could be a normal finding for someone with a history of hypertension, or a temporary elevation due to pain and anxiety from the injury.