A nurse is caring for a client who was transported to the emergency department (ED) with a major burn injury >30% from hot oil.
After assessing the airway, breathing, and circulation (ABC), what is the nurse's next priority action during the emergent phase of care?

Choice A rationale

Inserting an indwelling urinary catheter is important for monitoring urine output, which is a key indicator of fluid resuscitation adequacy in burn patients. However, establishing intravenous access for fluid resuscitation precedes catheter insertion, as inadequate fluid volume can lead to acute kidney injury despite monitoring.

Choice B rationale

Administering pain medications is crucial for client comfort and reduces the stress response, but it is not the immediate priority after assessing ABCs in a major burn injury. Restoring circulating fluid volume is paramount to prevent burn shock and maintain organ perfusion.

Choice C rationale

Inserting 2 large-bore intravenous catheters for fluid resuscitation is the next critical priority after assessing ABCs in a major burn injury. Large-bore access allows for rapid infusion of large volumes of crystalloid fluids to combat the massive fluid shifts and hypovolemic shock characteristic of emergent phase burns.

Choice D rationale

Preparing for a possible escharotomy may be necessary if circumferential burns impair circulation or ventilation, but it is not the immediate next step after ABC assessment. Fluid resuscitation takes precedence to prevent shock before addressing potential compartment syndrome or respiratory compromise requiring an escharotomy.

Choice A rationale

Circumoral cyanosis indicates reduced oxyhemoglobin saturation in the blood, leading to a bluish discoloration around the mouth. This is a direct clinical sign of hypoxemia, as inadequate oxygen transport to peripheral tissues becomes visible when desaturated hemoglobin levels exceed 5 g/dL. It signifies compromised gas exchange.

Choice B rationale

Lethargy in the context of respiratory compromise suggests cerebral hypoxia, where insufficient oxygen reaches brain tissue. Neurons are highly sensitive to oxygen deprivation, and impaired cellular respiration leads to decreased cognitive function, manifesting as drowsiness, confusion, and reduced responsiveness.

Choice C rationale

A pulse oximetry reading of 90% on room air indicates hypoxemia, as normal oxygen saturation levels typically range from 95% to 100%. This measurement reflects the percentage of hemoglobin binding sites occupied by oxygen. A reading of 90% signifies a significant reduction in oxygen-carrying capacity.

Choice D rationale

A heart rate of 86 bpm is within the normal adult resting range (60-100 bpm) and does not directly indicate hypoxemia. While prolonged hypoxemia can lead to compensatory tachycardia as the body attempts to increase oxygen delivery, this specific rate alone does not confirm oxygen deprivation.