The nurse reviews a note for a client who reports sharp chest pain that hurts worse when taking a deep breath and restlessness. The client's vital signs are Temperature 100 F (37.8 C), HR 104 BPM, RR 20 bpm with dyspnea, BP 114/62 mm Hg, and SpO2 90 percent on room air.
The nurse develops a plan of care to manage the client's suspected condition. Select six actions that would be appropriate for the nurse to include in the plan.

Managing an open pneumothorax requires immediate stabilization of the chest wall to restore pleural pressure dynamics. Knowledge of respiratory mechanics and the prevention of tension pneumothorax is essential to prioritize the correct occlusive dressing technique before proceeding with secondary medical interventions.

Choice A rationale: While a chest tube is the definitive treatment to re-expand the lung and drain the pleural space, it is not the first action. The immediate life-threatening air leak through the wound must be addressed first to stabilize the patient.

Choice B rationale: Administering high-flow oxygen is supportive and necessary, but it will not resolve the primary issue of an open sucking chest wound. Without sealing the atmospheric air entry point, the patient's respiratory effort will remain severely compromised by the pneumothorax.

Choice C rationale: Applying a sterile occlusive dressing taped on three sides creates a one-way valve. This allows trapped air to escape the pleural space during expiration while preventing atmospheric air from entering during inspiration, effectively preventing the development of a tension pneumothorax.

Choice D rationale: Initiating large-bore IV access is a critical part of trauma resuscitation to manage potential shock and administer fluids. However, in the hierarchy of trauma care, the "Breathing" intervention of sealing a sucking chest wound takes precedence over "Circulation" access.

The scenario requires applying principles of wound management, pain control, and infection prevention for thermal burns. Knowledge of tissue integrity, pharmacological intervention, and sterile surgical asepsis is necessary to prevent complications like syndactyly, infection, and severe pain during treatment.

Choice A rationale

Placing gauze between digits prevents skin surfaces from touching during healing. This essential intervention stops webbing or contractures, known as syndactyly, by maintaining anatomical separation of the fingers while absorbing exudate from the injured thermal burn sites.

Choice B rationale

Topical lotions containing vitamin E are inappropriate for acute thermal burns. Lotions can trap heat or introduce contaminants into open wounds. Specialized antimicrobial agents are required instead of over the counter moisturizers to ensure proper healing and safety.

Choice C rationale

Silver sulfadiazine is a broad spectrum topical antimicrobial used to prevent and treat wound sepsis in second and third degree burns. It effectively penetrates the eschar to reduce bacterial colonization, which is critical for successful skin regeneration.

Choice D rationale

Intact blisters serve as a natural sterile barrier against environment pathogens. Piercing or debriding small blisters increases the risk of infection and tissue trauma. Blisters should remain intact unless they interfere with joint movement or are significantly large.

Choice E rationale

Burn care and debridement are excruciatingly painful procedures. Administering systemic analgesics like morphine sulfate prior to care ensures the client reaches a therapeutic peak, which facilitates cooperation, reduces physiological stress, and manages severe pain during dressing changes.

Choice F rationale

Thermal burns destroy the primary skin barrier, leaving the client highly susceptible to healthcare associated infections. Strict sterile technique during wound care and dressing changes is mandatory to prevent sepsis and promote uncomplicated healing of the damaged tissues.