A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Explanation & Rationale
Choice A reason: Drawing blood for a CBC is important for assessing hemoconcentration, infection risk, and anemia, but it is not the immediate priority. Airway assessment takes precedence in burn victims, especially with facial involvement. Choice B reason: Inserting a urinary catheter helps monitor fluid status and renal perfusion, which is important in burn management. However, it is not the first priority when airway compromise is suspected. Choice C reason: Facial burns raise concern for inhalation injury, which can lead to airway edema and obstruction. Inspecting the mouth and airway is the priority to ensure patency and prevent respiratory failure. Early identification allows for timely intubation if needed. Choice D reason: Pain management is essential in burn care, but it is secondary to airway assessment. Administering IV analgesics without confirming airway stability could compromise respiratory function if sedation occurs.