While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

A. Placing the client into a shower and removing dead tissue is not an escharotomy; it refers to wound care practices.
B. An escharotomy involves making large incisions through the eschar (the thick, dead tissue) to relieve pressure and improve circulation, especially if the burn has caused circumferential constriction.
C. Non-surgical removal of dead tissue is typically done via debridement, not escharotomy.
D. Removing healthy skin for grafting is known as skin grafting, not escharotomy.

A. Urine output: A decrease in urine output from 480 mL/8 hr to 320 mL/8 hr indicates reduced renal perfusion or worsening heart failure. This finding suggests potential fluid retention or impaired kidney function, requiring further investigation and action.

B. Oxygen saturation: A drop in oxygen saturation from 95% to 88% indicates worsening oxygenation and potential respiratory distress or fluid overload. This finding necessitates further assessment and possible intervention to manage the client's respiratory status.

C. Weight: An increase in weight from 80 kg to 82.1 kg suggests fluid retention, which is common in heart failure. This weight gain indicates worsening fluid balance and may require adjustment in treatment to address fluid overload.

F. Breath sounds: The presence of scattered crackles on Day 4 suggests pulmonary congestion or fluid accumulation, which is concerning in heart failure. This finding indicates a worsening of the client’s condition and requires further evaluation and management.

Explanation of Incorrect Options:

D. Temperature: The temperature has slightly decreased but is still within a normal range. This finding does not require immediate further action.

E. Blood pressure: Although there is a change in blood pressure from 108/50 mm Hg to 138/80 mm Hg, this increase is not as critical as the other findings. It is important but less urgent in this context compared to the issues with oxygen saturation, urine output, weight, and breath sounds.