A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?

a. Wears clean gloves to remove the soiled dressing: This action is appropriate. Wearing clean gloves helps maintain aseptic technique and prevents contamination of the wound during dressing removal.

b. Uses slow, continuous pressure to flush the wound: This action is appropriate. Using slow, continuous pressure helps ensure effective irrigation of the wound without causing trauma to the tissue.

c. Places the syringe tip with angiocatheter 2.5 cm (1 in) above the open wound bed: This action is appropriate. Maintaining the appropriate distance ensures that the irrigation solution reaches the wound bed effectively without causing unnecessary trauma.

d. Opens irrigation supplies before removing the soiled dressing: This action is not appropriate. Opening irrigation supplies before removing the soiled dressing increases the risk of contamination. The nurse should first remove the soiled dressing using aseptic technique and then prepare the irrigation supplies.

a. A client who has an asymmetrical thorax:

An asymmetrical thorax can indicate a potentially life-threatening condition such as a tension pneumothorax, hemothorax, or flail chest. These conditions can compromise respiratory function and require immediate intervention to ensure the client's airway and breathing are maintained.

b. A client who has an open fracture of the femur:

An open fracture of the femur is a serious injury that requires prompt attention to prevent complications such as infection and excessive blood loss. However, it is typically classified as urgent rather than emergent unless there are signs of significant hemorrhage or compromised perfusion that threaten life.

c. A client who has preorbital edema:

Preorbital edema, which is swelling around the eyes, can be concerning and requires evaluation but is not typically life-threatening. This condition is less likely to require immediate intervention compared to compromised airway or breathing issues.

d. A client who has a deep-partial thickness burn on the lower extremities:

Deep-partial thickness burns are serious and painful injuries that require medical attention. However, they are usually not immediately life-threatening unless they involve a large percentage of body surface area or are accompanied by other critical injuries or complications. They are often categorized as urgent rather than emergent.