A nurse is contributing to the plan of care for a client who has partial-thickness and full-thickness burns on their lower extremities. Which of the following interventions should the nurse recommend including in the plan of care?

A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.

B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.

C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.

D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.

E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.

F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.

A. Measure the client's abdominal girth daily: Monitoring abdominal girth helps assess the progression or reduction of ascites and guides the effectiveness of interventions such as diuretic therapy or paracentesis. Daily measurements provide objective data for evaluating fluid accumulation.

B. Position the client supine with legs elevated: Elevating the legs while supine is more appropriate for peripheral edema, not ascites. For ascites, semi-Fowler’s or upright positioning is preferred to promote comfort and reduce pressure on the diaphragm.

C. Restrict the client's sodium intake to 3 g per day: Sodium restriction is typically recommended to manage fluid retention in ascites, but standard guidelines suggest limiting sodium to 2 g per day, not 3 g, to optimize effectiveness.

D. Keep the client's daily protein intake below 0.8 g/kg: Clients with cirrhosis and ascites often require adequate protein to prevent muscle wasting and malnutrition. Restricting protein excessively can worsen nutritional status and is generally not recommended unless the client has hepatic encephalopathy.