A client is admitted to the hospital with a burn injury that covers 30% of the total body surface area (TBSA). The client's weight is 70 kg. Using the Parkland formula, how much fluid should the client receive in the first 24 hours after the injury?

Correct answer: C) Increased pain and tenderness

Rationale: Increased pain and tenderness of the wound site may indicate an infection, as the inflammatory response is triggered by the presence of microorganisms. The nurse should obtain a wound culture and notify the provider of the suspected infection.

Incorrect options:

A) Serous drainage - This is a normal finding for a healing wound, as serous fluid is clear and watery and contains plasma and white blood cells. It does not indicate an infection unless it is cloudy, foul-smelling, or purulent.

B) Reddened periwound skin - This is a normal finding for a healing wound, as the increased blood flow to the area promotes oxygen and nutrient delivery to the wound site. It does not indicate an infection unless the redness is spreading, warm, or accompanied by other signs of inflammation.

D) Granulation tissue formation - This is a normal finding for a healing wound, as granulation tissue is new connective tissue that fills the wound bed and supports epithelialization. It does not indicate an infection unless it is pale, friable, or necrotic.

Correct answer: B) Instruct the client to splint the incision when coughing

Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.

Incorrect options:

A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.

C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.

D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.