A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

A. Cool the burn with ice water:

Not recommended: Cooling a burn with ice water directly is not recommended as it can lead to further tissue damage and complications. Instead, the burn should be cooled with cool (not cold) running water for a limited time and then covered with a clean, dry cloth.

B. Administer opioid analgesics:

Recommended: Severe burns can cause excruciating pain, and opioid analgesics are often necessary to manage this pain effectively. However, the specific opioid, dosage, and route of administration should be determined by the healthcare provider based on the client's condition and pain level.

C. Administer systemic antibiotics:

Not routinely recommended: Unless there are signs of infection or the burn involves deep tissue damage, systemic antibiotics are not typically administered prophylactically for burn injuries. However, if there are signs of infection, such as redness, swelling, warmth, or drainage from the burn site, antibiotic therapy may be initiated based on culture and sensitivity results.

D. Administer benzodiazepines for anxiety management:

Considered: Severe burns can cause significant psychological distress and anxiety in patients. Benzodiazepines may be considered to manage acute anxiety and agitation in these situations. However, the decision to administer benzodiazepines should be made based on the client's overall condition, vital signs, and response to non-pharmacological interventions for anxiety.

E. Lay the head of the bed flat:

Not recommended: In a client with severe burns who is experiencing increased work of breathing, anxiety, and rapid breathing, it is generally more beneficial to elevate the head of the bed slightly (semi-Fowler's position) to improve respiratory mechanics and reduce anxiety-related respiratory distress.

A.Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.

B.High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).

C.Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.

D.A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.