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Difficulty: MediumPhysiological Adaptation

A nurse in the emergency department receives a client who sustained full-thickness thermal burns to the face, neck, and anterior chest from a house fire. Arrange the following nursing interventions in the priority order they should be performed. All options must be used.

  1. 1Assess the client's airway patency and respiratory effort.
  2. 2Administer 100% humidified oxygen via a non-rebreather mask.
  3. 3Insert two large-bore intravenous catheters.
  4. 4Initiate fluid resuscitation with prescribed Lactated Ringer's solution.
  5. 5Estimate the total body surface area burned using the Rule of Nines.

Answer

The correct priority order follows the primary and secondary survey framework (Airway, Breathing, Circulation). The nurse must first assess the airway, then administer oxygen, followed by establishing IV access, initiating fluids, and finally estimating the burn extent.
In the emergent phase of burn care, life-saving interventions must follow the ABCs of trauma. Securing a patent airway is the absolute first priority, especially for facial and neck burns that can rapidly swell. This is immediately followed by supporting breathing with 100% oxygen to counteract carbon monoxide and hypoxia. Once oxygenation is supported, the nurse addresses circulation by establishing large-bore IV access and initiating aggressive fluid resuscitation to prevent burn shock. Finally, during the secondary survey, the nurse calculates the total body surface area burned to refine the long-term fluid resuscitation plan.

Step-by-Step Solution

1
Prioritize Airway (A).
The nurse assesses the client's airway patency and respiratory effort.
Facial and neck burns carry a severe risk of inhalation injury and rapid airway occlusion from progressing edema.
2
Prioritize Breathing (B).
The nurse administers 100% humidified oxygen via a non-rebreather mask.
Clients exposed to house fires are at high risk for carbon monoxide poisoning and hypoxia, requiring immediate high-flow oxygen.
3
Prioritize Circulation (C).
The nurse inserts two large-bore intravenous catheters.
Severe burns cause massive capillary leak and fluid shifts. Vascular access must be secured before hypovolemic shock progresses.
4
Intervene for Circulation.
The nurse initiates fluid resuscitation with prescribed Lactated Ringer's solution.
Isotonic fluid replacement is critical to maintain cardiac output, organ perfusion, and prevent fatal burn shock.
5
Perform the Secondary Survey.
The nurse estimates the total body surface area burned using the Rule of Nines.
Once life-threatening ABC issues are stabilized, the nurse assesses the full extent of the injury to guide ongoing fluid administration calculations.

Key Concept

Emergent Management of Burn Injuries
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Topics

Physiological Adaptation

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