The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first?
A. Assesses level of consciousness and pupillary reactions
B. Ascertains the time food or liquid was last consumed
C. Auscultates breath sounds over the trachea and mainstem bronchi
D. Measures abdominal girth and auscultates bowel sounds
Correct Answer: C. Auscultates breath sounds over the trachea and mainstem bronchi.
Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation.
Option A: Knowing the level of consciousness is important to assess oxygenation to the brain. In most cases, neurologic status won’t be altered in the early stages of burn injury. Use the Glasgow Coma Scale to trend the patient’s neurologic status throughout the resuscitation.
Option B: Ascertaining time of last food intake is important in case intubation is necessary (the nurse would be more alert for the signs of aspiration). However, assessing air exchange is the most important intervention at this time.
Option D: Measuring abdominal girth is not relevant in this situation. If there is edema or evidence of burn in the upper airways, assess whether an endotracheal (ET) tube is needed to maintain the airway.
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