The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago.

Which complication is most important for the PN to anticipate?

Choice B rationale:

Giving the wife a straw to help facilitate the client's drinking is not the most appropriate action in this situation. The client's facial paralysis and inability to move his left side could be indicative of a possible stroke or cerebral vascular accident (CVA). Before attempting to give the client fluids, it is essential to assess his swallowing reflex to prevent aspiration and ensure safety. Using a straw may not address the underlying issue.

Choice C rationale:

Assisting the wife and carefully giving the client small sips of water without assessing the swallowing reflex can be risky. If the client has impaired swallowing, this action could lead to aspiration and further complications. Assessing the client's ability to swallow is the priority to ensure safe oral intake.

Choice D rationale:

Obtaining thickening powder before providing any more fluids is premature without first assessing the client's swallowing ability. Thickened liquids may be necessary if the client has dysphagia, but the nurse should assess the client's condition and consult with the healthcare provider before making this decision. Assessing the swallowing reflex is the first step in determining the appropriate course of action.

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.