A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first?
a. Assess level of consciousness and pupil-lary reactions.
b. Ascertain the 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.
C
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. Absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important, in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air ex-change is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
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