A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inflammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer fluids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's fluid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous fluids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice A Reason: This is incorrect because the client is not unconscious, as the GCS score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.

Choice B Reason: This is correct because the client can follow simple motor commands, as the GCS score for best motor response is 5, which means the client can localize pain by moving his limbs away from the source of stimulation.To interpret the Glasgow Coma Scale (GCS) score provided in the scenario:Eye Opening (E): 3 - The client opens their eyes in response to verbal stimuli.Best Verbal Response (V): 5 - The client is oriented and able to engage in coherent conversation.Best Motor Response (M): 5 - The client can localize pain or follow motor commands (depending on additional context). The total GCS score would be 3 + 5 + 5 = 13, indicating a mild level of impairment or responsiveness.

Choice C Reason: This is incorrect because the client is able to make vocal sounds, as the GCS score for best verbal response is 5, which means the client can orient himself to person, place, and time.

Choice D Reason: This is incorrect because the client does not open his eyes when spoken to, as the GCS score for eye opening is 3, which means the client only opens his eyes in response to pain.