A nurse is caring for a client with acute pancreatitis in the ICU. The client develops sudden dyspnea and oxygen saturation of 85%. Which intervention should the nurse prioritize?

Choice A reason: Pain medication is important for burn patients due to severe pain from exposed nerve endings. However, in the ABCDE approach, circulation (fluid status) takes precedence over pain management. A 30% burn causes significant fluid loss, risking hypovolemic shock, making IV fluids the priority to stabilize the patient before addressing pain.

Choice B reason: A 30% burn injury to the lower extremities causes significant plasma leakage, leading to hypovolemia and potential shock. Administering IV fluids, typically via the Parkland formula, restores intravascular volume, maintains blood pressure, and ensures organ perfusion. In the ABCDE approach, circulation is prioritized, making fluid resuscitation the first intervention.

Choice C reason: Cleaning and dressing burn wounds prevent infection, a major complication due to loss of the skin barrier. However, this is not the immediate priority in the acute phase. Fluid resuscitation addresses life-threatening hypovolemia first, as per the ABCDE approach, ensuring circulatory stability before wound care is initiated.

Choice D reason: A tetanus booster prevents infection from Clostridium tetani, especially in contaminated burns. While important, it is not the first priority in the acute management of a 30% burn. Fluid resuscitation addresses immediate life-threatening hypovolemia, which takes precedence over prophylactic measures like tetanus vaccination in the ABCDE framework.

Choice A reason: Deep partial- and full-thickness burns to the neck and chest risk airway edema due to thermal injury, leading to obstruction. The resuscitation phase prioritizes the ABCDE approach, with airway as the first concern. Ensuring a patent airway via assessment or intubation prevents respiratory arrest, making this the most critical intervention.

Choice B reason: Pain medication is essential for burn patients due to severe pain from nerve exposure, but it is not the priority in the resuscitation phase. The ABCDE approach places airway and breathing above pain management. Airway compromise from neck burns can be fatal, making pain control secondary to airway patency.

Choice C reason: Inserting an indwelling urinary catheter monitors urine output, critical for assessing fluid resuscitation in burns. However, in the ABCDE approach, airway takes precedence over circulation monitoring. Neck and chest burns risk rapid airway obstruction, making catheter insertion a secondary intervention after ensuring airway and breathing are stable.

Choice D reason: Fluid resuscitation is vital in burns to correct hypovolemia from plasma leakage, but it follows airway and breathing in the ABCDE approach. Neck and chest burns pose an immediate airway threat due to edema, requiring prioritization of airway patency to prevent respiratory failure before addressing circulatory needs.