Question

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, his vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.

A. Cleaning the burns with hydrogen peroxide

B. Covering the burns with saline-soaked towels

C. Starting an I.V. infusion of lactated Ringer's solution

D. Placing ice directly on the burn areas

E. Administering 6 mg of morphine I.V.

F. Administering tetanus prophylaxis as ordered

Answer 1

The appropriate nursing interventions for a client with deep partial-thickness and full-thickness burns are starting an IV infusion, administering morphine for pain management, and administering tetanus prophylaxis.

Step-by-step explanation:

For a client with deep partial-thickness and full-thickness burns over 15% of his body, appropriate nursing interventions include:

1. Starting an I.V. infusion of lactated Ringer's solution to offset dehydration and electrolyte imbalance caused by the burns.
2. Administering 6 mg of morphine I.V. to manage pain.
3. Administering tetanus prophylaxis as ordered to prevent infection.