While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound.

Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Choice A rationale:

Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.

Choice B rationale:

Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.

Choice C rationale:

Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.

Choice D rationale:

Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.

The correct answer is Choice B: Advise the client that lifestyle changes often take several weeks to be effective.

Choice B rationale: Exercise is known to improve sleep quality and reduce the time it takes to fall asleep; however, these benefits may not be immediate. Lifestyle modifications, such as incorporating regular physical activity, typically require several weeks before noticeable improvements in sleep patterns and overall health are observed. By informing the client about this expected timeframe, the nurse promotes realistic expectations and encourages adherence to the exercise program.

Choice A rationale: Encouraging daily exercise to eliminate bedtime wakefulness may be counterproductive, as overexertion can lead to increased arousal and impaired sleep quality. Additionally, daily exercise might be too rigorous or impractical for some individuals, potentially leading to burnout or injury. It is essential to tailor exercise recommendations to the client's fitness level, preferences, and goals.

Choice C rationale: While obtaining information about the client's exercise schedule is helpful in assessing their adherence and progress, it does not directly address the issue of sleep onset difficulties. The nurse should focus on providing education and guidance on the expected timeline for observing sleep improvements with exercise.

Choice D rationale: Weight loss is a potential outcome of increased physical activity but is not directly correlated with improvements in sleep onset latency. Focusing solely on weight loss may overlook other essential aspects of sleep hygiene and healthy lifestyle changes. The nurse should emphasize the broader benefits of exercise and provide a comprehensive approach to addressing the client's concerns.