QLexNursing

⭐ In the emergent phase of burn injury, the most critical priority is maintaining airway, breathing, and circulation (ABCs), and this scenario shows clear signs of hypovolemic shock (BP 90/58, HR 130).

⭐ Burn injuries cause massive fluid shifts and capillary leakage, leading to rapid plasma loss, requiring aggressive and immediate IV fluid resuscitation.

⭐ Establishing two large-bore (18G or larger) IV lines ensures rapid delivery of crystalloids, guided by the Parkland formula.

⭐ Without timely fluid replacement, the client is at high risk for burn shock, decreased organ perfusion, and fatal circulatory collapse.

⭐ Therefore, initiating rapid fluid resuscitation is the first and most lifesaving intervention during the emergent phase.

Obtain a detailed medical history and allergies

⭐ Gathering a medical history is important but is not the first priority during the emergent phase of burn care.

⭐ The client shows critical signs such as hypotension, tachycardia, tachypnea, and soot around the mouth, which indicate immediate threats to circulation and airway.

⭐ History-taking delays lifesaving interventions like fluid resuscitation or airway protection, and can worsen the patient’s outcome.

⭐ In emergency burns, history is collected after stabilization, not before.

⭐ Thus, this option is unsafe as an initial action because it does not address life-threatening concerns.

Apply topical antibiotic ointment

⭐ Topical antibiotics are used during the acute phase, not during the emergent phase, when immediate life threats must be addressed.

⭐ At this stage, the client is hemodynamically unstable, with signs of shock and respiratory distress, which require urgent action.

⭐ Applying ointment does not protect against fluid loss, does not correct shock, and does not secure the airway.

⭐ Wound care comes after stabilization, airway management, and IV fluid therapy begin.

⭐ Therefore, this intervention is not appropriate as the first step.

Administer pain medication to manage discomfort

⭐ Although pain management is essential, it is never the first intervention during burn emergencies when circulation and airway may be compromised.

⭐ The client has a dangerously low blood pressure (90/58), and opioids could worsen hypotension, leading to circulatory collapse.

⭐ Administering pain medication first could delay lifesaving fluid resuscitation, which is critical for perfusion and preventing burn shock.

⭐ Pain medication is given after stabilization of vital signs and securing the IV access for fluids.

⭐ Thus, while important, pain control is not the first priority intervention.