An older adult client with burns has a white blood cell count of 10,000/mm3 . The client is afebrile with a heart rate of 110 beats/min, a respiratory rate of 20 breaths/min, and blood pressure of 112/68 mm Hg
The client's wound is pale, and edema is noted in the surrounding tissues. Which intervention by the nurse is most appropriate? a. Assess the client's skin for signs of ade-quate perfusion.
b. Calculate intake and output ratio for the last 24 hours.
c. Prepare to obtain blood and wound cul-tures.
d. Place the client in an isolation room.
C
Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. The other options would yield important data but do not take priority over determining whether the client has an infection.
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