Burns and Burn Injury Q 84 - Gyan Darpan : Learning Portal
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Wednesday 30 March 2022

Burns and Burn Injury Q 84

The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?
    A. Assess level of consciousness and pupillary reactions.
    B. Ask the client at what time food or liquid was last consumed.
    C. Auscultate breath sounds over the trachea and mainstem bronchi.
    D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.

Correct Answer: C. Auscultate breath sounds over the trachea and mainstem bronchi.

Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly. Close physical examination of patients with inhalation injury can reveal signs of smoke inhalation, including facial burns, perioral burns, and singed nasal hairs. This warrants laryngoscopy and evidence of significant edema, blisters, or ulcerations should lead to consideration for intubation to stabilize the airway.

Option A: Neurovascular assessment may be done after establishing a patent airway. Inhalation of smoke also leads to the absorption of many toxins in the blood, including carbon monoxide and cyanide, thereby causing the entire body to be affected, and making inhalational injury a systemic insult.
Option B: History taking can be done after the patient has been deemed stable. It is well known that rapid diagnosis and treatment are key when it comes to inhalational burns, as acute complications, which sometimes go unnoticed, are the reason behind long-term sequels and the high mortality rate seen with this type of injury.
Option D: GI assessment is not a priority. Edema of the oral mucosa and/or the trachea can develop within 0.5 hours of the time of injury and can progress to mucosal necrosis within 12-24 hours. Supraglottic injury, swelling, and resulting obstruction of the airway occur more commonly in children due to the smaller size of the trachea, and relatively large epiglottis.

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