A nurse is planning to perform nasotracheal suction for a client who has COPD and an artificial airway.
Which of the following actions should the nurse take?

Choice A rationale

While infection is a significant risk for burn patients due to compromised skin integrity, it is not the immediate priority for a client with head, neck, and chest burns. Infection typically manifests after 24 to 48 hours and requires ongoing management. The initial focus must be on immediate life threats, and airway compromise is the most critical threat in the first hours.

Choice B rationale

Fluid imbalance is a serious concern with extensive burns, as capillary leakage leads to third spacing of fluids and a risk of hypovolemic shock. Fluid resuscitation is a critical intervention, but it is secondary to establishing and maintaining a patent airway. The client must be able to breathe before any other treatments can be effective.

Choice C rationale

Paralytic ileus is a potential complication of major burn injury due to stress-related changes in gastrointestinal motility. However, it is not an immediate, life-threatening risk. This complication typically develops later in the course of treatment, and its management involves supportive care. The immediate priority is always airway management.

Choice D rationale

For a client with burns to the head, neck, and chest, airway obstruction is the most critical and immediate risk. These areas are prone to severe edema from the inflammatory response, which can cause rapid and complete airway occlusion. Assessment for signs of inhalation injury and proactive intubation may be necessary to secure the airway before swelling progresses.

Choice A rationale

This statement describes a skin graft, not an escharotomy. A skin graft is a surgical procedure where healthy skin is transplanted from a donor site to cover a wound, typically done after the wound bed is debrided of all dead tissue. An escharotomy is an immediate procedure to relieve pressure and restore circulation.

Choice B rationale

An escharotomy is a surgical procedure, not a nonsurgical one. It involves making incisions into the eschar, which is the dead, leathery tissue that forms over a full-thickness burn. These incisions are deep enough to relieve pressure and improve circulation to the underlying tissue.

Choice C rationale

Escharotomy is a surgical procedure involving large incisions through the tough, non-elastic eschar. This is performed to relieve compartment syndrome, a condition where the constricted tissue impairs blood flow and neurological function. The incisions restore circulation and prevent ischemia and necrosis of the underlying viable tissues.

Choice D rationale

This statement describes hydrotherapy or debridement, which is a process of using water to remove dead tissue, not an escharotomy. Hydrotherapy is often used in burn care to cleanse wounds and prepare them for grafting, but it does not involve surgical incisions to relieve pressure.