A nurse is planning to change the dressings on a school-age child who has sustained multiple burns. Which of the following actions should the nurse plan to take?

A. Apply a transparent dressing to the wound. Transparent dressings are not appropriate for active bleeding as they are too thin and do not absorb blood or provide compression to control hemorrhage.
B. Irrigate the wound with sterile water. Wound irrigation is not a priority when a client is actively bleeding. Controlling the bleeding takes precedence over cleaning the wound.
C. Apply direct pressure to the wound with thick dressing material. Direct pressure is the first-line intervention to control external bleeding. Applying firm pressure with a thick dressing helps compress the blood vessels and minimize blood loss.
D. Tie a tourniquet around the leg distal to the wound. A tourniquet should be applied proximal (above) the wound if needed and only after direct pressure fails to control the bleeding. Applying it distal is ineffective and potentially harmful.

A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.