The nurse in the burn unit provides discharge instructions for a client who received a skin graft due to deep partial-thickness burns from a work accident at a chemical plant.
Which instruction should the nurse prioritize?

Prioritizing interventions for autonomic dysreflexia in quadriplegic clients requires understanding the physiological response to noxious stimuli below the injury level. Critical thinking is applied to determine the most immediate action to lower dangerous hypertensive levels and prevent intracranial hemorrhage or seizures.

Choice A rationale

Nitrates are used to manage severe hypertension in autonomic dysreflexia, but pharmacological intervention is not the first step. Non-pharmacological measures to reduce blood pressure should be attempted immediately before administering medications to the client to ensure safety.

Choice B rationale

Assessing for bladder distention is vital because it is the most common trigger for autonomic dysreflexia. However, physiological stabilization via positioning must occur before or simultaneously with the search for the underlying cause to prevent immediate vascular complications.

Choice C rationale

Monitoring the heart rate is necessary as bradycardia often accompanies the hypertensive surge in autonomic dysreflexia. While important for assessment, obtaining vital signs does not actively lower the blood pressure or address the immediate risk of a stroke.

Choice D rationale

Placing the client in a high-Fowler's position is the priority action because it utilizes gravity to cause orthostatic pooling of blood in the lower extremities. This immediate intervention helps decrease the dangerously high blood pressure and reduces intracranial pressure..

Evaluating post surgical and post pulmonary embolism recovery requires assessing functional mobility, respiratory stability, and wound healing. Knowledge of normal rehabilitation milestones and the resolution of thromboembolic symptoms is necessary to determine if the client is meeting expected outcomes.

Choice A rationale

Independent performance of activities of daily living indicates restored functional capacity and successful rehabilitation after surgery. It demonstrates that the client has regained sufficient strength and coordination to manage self care tasks without exhausting their cardiovascular reserves.

Choice B rationale

Unintentional weight loss of 27 lbs within six weeks is an abnormal finding that suggests underlying pathology, malnutrition, or chronic illness. It does not indicate improvement and instead necessitates further medical investigation to rule out complications.

Choice C rationale

Transitioning to independent walking with a cane shows progress in gait stability and weight bearing tolerance on the prosthetic joint. This movement away from more restrictive assistive devices like walkers is a positive indicator of recovery.

Choice D rationale

Significant bruising and discoloration are concerning signs, potentially indicating a bleeding disorder or complications from ongoing anticoagulation therapy. This finding represents a setback or a new problem rather than a sign of successful clinical improvement.

Choice E rationale

Increased pain with movement in the surgical area suggests potential complications such as infection, prosthesis loosening, or hip dislocation. Expected progress involves a steady decrease in pain levels as the surgical site heals over the weeks.

Choice F rationale

The absence of shortness of breath and chest pain indicates that the pulmonary embolism has resolved and gas exchange is stable. This respiratory comfort suggests that pulmonary perfusion has been restored and the lungs are healing.

Choice G rationale

An oxygen saturation of 95 is within the normal range of 95 to 100 percent. This indicates adequate arterial oxygenation and demonstrates that the client no longer requires supplemental oxygen to maintain systemic tissue perfusion after recovery.

Choice H rationale

A visible hairline scar without redness, swelling, or drainage confirms successful primary intention healing of the surgical incision. This indicates that the skin integrity is restored and the risk of localized or systemic infection is decreasing.