A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Choice A reason: Obtaining a prostate-specific antigen (PSA) blood level test is important for screening and monitoring prostate health but does not directly reduce the risk factors for benign prostatic hyperplasia (BPH). PSA tests can help in early detection of prostate issues, but they are not preventive measures.

Choice B reason: Taking vitamin supplements is not specifically proven to reduce the risk of BPH. While maintaining overall nutritional health is important, there is no direct evidence that vitamin supplements alone can prevent BPH. It's better to focus on a balanced diet and healthy lifestyle choices.

Choice C reason: Consuming a high-protein diet does not specifically reduce the risk of BPH. While protein is an essential nutrient for overall health, there is no clear evidence that it has a direct impact on preventing BPH. A balanced diet that includes a variety of nutrients is more beneficial for general health and well-being.

Choice D reason: Increasing physical activity is one of the recommended lifestyle changes to reduce the risk of BPH. Regular physical activity can improve overall health, help maintain a healthy weight, and potentially reduce the risk of BPH. Physical activity is associated with better prostate health and can help mitigate some of the risk factors associated with BPH, such as obesity and sedentary lifestyle.

Condition:

Postoperative infection

2 Actions:

1. Administer prescribed antibiotics.
2. Culture wound drainage.

2 Parameters:

1. Temperature.
2. White blood cell count.

Rationale for correct condition:

A postoperative infection is the most likely condition because the patient has elevated white blood cell count (11,000/mm³) and a slightly elevated temperature (99.8°F). These findings suggest a systemic inflammatory response, potentially from infection. The presence of a recent surgical wound increases the risk of bacterial contamination. The absence of redness or drainage does not rule out deeper tissue infection. The patient’s symptoms align with early signs of an infectious process.

Rationale for the two correct actions:

1. Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
2. Culture wound drainage: This identifies the causative organism and guides appropriate antibiotic therapy. Even if the wound appears clean externally, culturing can confirm or rule out deeper infection.

Rationale for parameters to monitor:

1. Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
2. White blood cell count: Elevated levels are a marker of infection or inflammation. Monitoring changes in WBC count can indicate if treatment is effective.

Rationale for incorrect conditions:

1. Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
2. Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
3. Deep vein thrombosis (DVT): The client’s normal vital signs and lack of redness or swelling in the residual limb make DVT less likely.

Rationale for incorrect actions to take:

1. Request NPO prescription: There is no evidence of gastrointestinal issues or surgery requiring this intervention.
2. Elevate residual limb to reduce swelling: While useful in managing swelling, there is no current sign of significant limb edema requiring elevation.
3. Educate on incentive spirometer use: This is preventive for respiratory complications but unrelated to infection management.

Rationale for incorrect parameters to monitor:

1. Adherence to activity prescription: While important for recovery, it does not directly address infection.
2. Residual limb redness or swelling: Although relevant to infection, there is no current evidence of redness or swelling in the notes.
3. Pain intensity and characteristics: Pain is already being managed with morphine, and its current level (5/10) does not directly indicate infection.