A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and

c. Check the drainage tubing for obstructions.

a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.

b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.

c. Checking the drainage tubing for obstructions is essential to ensure proper flow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can affect the effectiveness of the procedure and potentially lead to complications.

d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.

e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.

By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.

The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.

a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.

c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.

d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.