What is the best action for the nurse to take? A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break.
A. Remove the raised skin because the blister has already broken. B. Wash the area with soap and water to disinfect it. C. Apply a weakened alcohol solution to clean the area. D. Clean the area with normal saline solution and cover it with a protective dressing.
Clean the area with normal saline solution and cover it with a protective dressing.-rationale: the nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. soap and water and alcohol are too harsh. the bodys first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.client needs category: physiological integrityclient needs subcategory: reduction of risk potentialcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1190.