A 6-year-old boy has been admitted to the hospital with burns. The nurse notes black sputum. What is the priority nursing intervention?
A) Obtain a brief history.
B) Elicit a description of the burn.
C) Obtain an in-depth history.
D) Obtain a brief history, evaluate the child, and provide emergency care.
D
Response:
Carbonaceous (black-colored) sputum is a sign of potential airway injury due to smoke inhalation. Therefore, the nurse should obtain a brief history while simultaneously evaluating the child and providing emergency care. If the burn does not pose an immediate life-threatening risk, the nurse would obtain an in-depth history and elicit a description of the burn.
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