question archive 39- A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea
39- A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea
Subject:NursingPrice:2.86 Bought3
39- A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea. The client's blood pressure is 82/40 mmHg and temperature 96 F (36.6 C). Which action is most important for the nurse to take?
a. Increase the room temperature.
b. Assess the oxygen saturation.
c. Continue to monitor vital sign.
d. Notify the rapid response team.
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D
Step-by-step explanation
The nurse needs to notify the rapid response team for immediate intervention. The patient is hypovolemic and may go into shock as evidenced by the hypotension. The patient needs volume repletion, and definitive care such as surgical wound management and antibiotic cover.
