Burns and Burn Injury Q 66

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Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse’s best action?

  

    A. Administers a laxative

    B. Documents the finding

    C. Increases the IV flow rate

    D. Repositions the client onto the right side

    

    

Correct Answer: B. Documents the finding

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Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time.

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Option A: Do not give the patient laxative. The emergent phase starts with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of patient care involves maintaining an adequate airway and treating the patient for burn shock.

Option C: Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during the initial 24–72 hr after burn injury. Fluid replacement formulas partly depend on admission weight and subsequent changes.

Option D: Maintain proper body alignment with supports or splints, especially for burns over joints. This promotes functional positioning of extremities and prevents contractures, which are more likely over joints.

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