A client with partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. What action should the nurse take first?

A client with partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. What action should the nurse take first?

• A. Remove the client's clothing
• B. Evaluate whether the client has inhaled smoke
• C. Insert a venous access device in an unaffected arm
• D. Determine the extent of the burns, using the rule of nines

Answer: (B)

The most important action is to assess and secure the airway because inhalation injury can rapidly compromise breathing and lead to airway edema even if skin burns seem limited. In a client exposed to smoke, prioritize evaluating for inhalation injury by looking for signs such as facial burns, singed nasal hairs, soot in the sputum, hoarseness, or stridor, and by checking respiratory status and oxygen saturation. If inhalation injury is suspected, prepare to provide high-flow oxygen and be ready for early airway support, including possible endotracheal intubation. Only after addressing the airway should you proceed with other steps like removing clothing to prevent further thermal injury, estimating burn extent, or establishing vascular access, as those actions are important but secondary to securing the airway in this scenario.

The most important action is to assess and secure the airway because inhalation injury can rapidly compromise breathing and lead to airway edema even if skin burns seem limited. In a client exposed to smoke, prioritize evaluating for inhalation injury by looking for signs such as facial burns, singed nasal hairs, soot in the sputum, hoarseness, or stridor, and by checking respiratory status and oxygen saturation. If inhalation injury is suspected, prepare to provide high-flow oxygen and be ready for early airway support, including possible endotracheal intubation. Only after addressing the airway should you proceed with other steps like removing clothing to prevent further thermal injury, estimating burn extent, or establishing vascular access, as those actions are important but secondary to securing the airway in this scenario.