While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound.

Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The correct answer and explanation are:

A - Ask the client to describe what happened. Correct

This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.

B - Inform the charge nurse of the situation.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.

C - Complete a client adverse incident report.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.

D - Call the agency-based client advocate.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns.

The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.

The correct answers are Choices B, C, D, and E.

Choice A rationale: Dentures should remain in place to preserve facial structure and dignity. Removing them may cause facial collapse, distressing the family during viewing and violating postmortem presentation standards.

Choice B rationale: Gently closing the eyes prevents ocular drying and maintains a peaceful appearance. If eyelids resist closure, moistened cotton balls may be used temporarily to assist with natural positioning.

Choice C rationale: Placing a small pillow under the head elevates it, preventing blood pooling and facial discoloration due to livor mortis. It supports a natural, respectful presentation for family viewing.

Choice D rationale: Applying a body shroud ensures hygienic containment and visual dignity. It’s standard practice before transport and aligns with institutional protocols for respectful postmortem care.

Choice E rationale: Removing resuscitation equipment reduces trauma triggers for the family, restores environmental calm, and supports emotional closure. It also complies with facility standards for postmortem room preparation.