A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds were absent in all four abdominal quadrants. Which is the nurse's best ac-tion?
a. Administer a laxative.
b. Document the finding.
c. Prepare to insert a nasogastric (NG) tube.
d. Reposition the client on the right side.
C
Decreased or absent peristalsis is a frequent response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. The result is often a paralytic ileus. Clients who have burns greater than 25% TBSA or who are intubated generally need to have an NG tube inserted.
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