A client who has an extensive burn injury develops inflammation that covers the entire body. What is the nurse's best action?
a. Notify the health care provider imme-diately.
b. Document the assessment.
c. Take the client's temperature.
d. Ask for an order for antibiotic therapy.
B
The inflammatory response depends on how severe the initiating event was. It would not be un-expected to have an extensive inflammatory reaction to a severe burn injury. The nurse would not have to notify the health care provider immediately, because this would not signal an emergency. This does not necessarily indicate a fever or an infection; however, the client with extensive burns would be prone to developing infection.
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