A nurse is collecting data from an older adult client who has a potassium level of 3.2 mEq/L. Which of the following findings should the nurse expect?

Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.

A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.

B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.

C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.

Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.