A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following Instructions should the nurse include in the teaching?

Initial management of a client with partial-thickness burns to the upper torso requires rapid assessment of airway and breathing because thermal injuries can compromise ventilation, especially when burns involve the chest and may cause airway edema or impaired chest expansion. Burn injury triggers a systemic inflammatory response that can also affect oxygenation and perfusion. Priority nursing care follows ABC principles, with immediate focus on ensuring adequate oxygen delivery and early detection of respiratory compromise.

Rationale:
A. Using aseptic technique during wound care is important for preventing infection in a client with partial-thickness burns, but it is not the priority action on initial admission. Infection control measures are essential later during ongoing wound management, once airway and breathing stability are confirmed. Immediate life-threatening concerns take precedence over wound care procedures.

B. Obtaining oxygen saturation is the priority because upper torso burns can lead to inhalation injury, airway edema, or restricted chest wall movement. Monitoring oxygenation provides immediate information about respiratory status and helps detect early hypoxia. In burn care, ensuring adequate ventilation and oxygen delivery is the first step in stabilizing the client following Burn injury.

C. Checking the WBC count is useful for monitoring infection or inflammatory response, but it is not an immediate priority during initial burn assessment. Laboratory values do not provide real-time information about airway patency or oxygenation. Priority must remain on rapid physiologic stabilization rather than diagnostic review.

D. Regulating IV fluids is an important aspect of burn management to maintain perfusion and prevent hypovolemic shock, but it is secondary to immediate assessment of airway and breathing. Fluid resuscitation is guided after initial stabilization and ongoing monitoring of vital organ function. Oxygenation and respiratory status must be addressed first.

Autonomy in healthcare refers to a client’s right to make informed decisions about their own care, including treatment preferences, goals, and end-of-life choices. In clients with terminal illness, respecting autonomy is especially important because care often shifts toward comfort, dignity, and individualized priorities. Nurses support autonomy by involving clients in decision-making, providing clear information, and honoring expressed wishes. This approach ensures care aligns with the client’s values rather than being solely provider-directed.

Rationale:
A. Following facility protocol when performing a procedure ensures safety and standardization of care, but it does not directly promote client autonomy. While protocols are important for consistency and risk reduction, they do not involve the client in decision-making or respect personal preferences.

B. Administering pain medication on a routine schedule promotes comfort and symptom control but is more related to beneficence than autonomy. It does not necessarily reflect the client’s participation in decisions about their care plan or treatment goals.

C. Keeping an agreement made with the client to administer an antiemetic medication demonstrates trust and reliability, but it primarily reflects fidelity rather than autonomy. While honoring agreements is important, it does not specifically involve the client in decision-making processes.

D. Including the client’s input when setting treatment goals directly supports autonomy by involving them in decisions about their care. In conditions such as Terminal cancer, this ensures care aligns with the client’s values, preferences, and desired quality of life. This shared decision-making is the clearest example of respecting and promoting autonomy.