A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?
Explanation & Rationale
A. Insert an 18-gauge IV catheter: While establishing IV access is important for fluid resuscitation and medication administration, it is not the immediate priority in this scenario. B. Apply 100% humidified oxygen: This action is critical as the client is showing signs of potential airway compromise (drooling and hoarseness), which may indicate edema or inhalation injury. Providing humidified oxygen can help maintain airway patency and support respiratory function, making it the top priority. C. Obtain a baseline ECG: While cardiac monitoring is important in many emergency situations, it is not the immediate concern in this case, where airway issues are evident. D. Obtain a blood specimen for ABG analysis: Although assessing arterial blood gases can provide useful information about the client's respiratory status, it is not the first priority when there are clear signs of airway compromise. Addressing the airway issue is critical to prevent respiratory failure.