What is the priority nursing intervention for a client who is admitted to the emergency department with burns over an estimated 27% of the upper body surface area?
1. Insert a large-caliber IV line.
2. Administer morphine intramuscularly.
3. Establish an airway.
4. Administer tetanus toxoid.
Establishing a patent airway is the priority intervention. Prophylactic intubation is initiated if heat has been inhaled or if the neck, head, or face is involved. Swelling of the upper airways can progress to obstruction.
Fluid replacement can best be achieved using a large-caliber peripheral IV catheter, and morphine sulfate is appropriate for analgesia in a burn client. Although these are priorities, they are secondary to establishing a patent airway. Administering tetanus toxoid is a secondary priority.
CN: Reduction of risk potential; CL: Synthesize