Fundamentals Question #54

Question

The nurse is caring for a client with severe burns of the face and head. In which position should this client be placed?

Answers

  1. Supine
    • Rationale:

      This answer is not correct because supine is a position where a person is lying flat on their back, facing forward. One way to help reduce airway obstruction from edema is by elevating the client’s head to a semi-Fowler position. The semi-Fowler position is a position when the client is on their back but the head and trunk is raised to generally 30 to 45 degree angle (most commonly, a 30 degree angle).

  2. Bedrest with elevated limbs
    • Rationale:

      This answer is not correct because bedrest with limbs elevated is an intervention used for a deep vein thrombosis (DVT). This would reduce edema of the lower extremities, but not of the face and head. One way to help reduce airway obstruction from edema is by elevating the client’s head to a semi-Fowler position. The semi-Fowler position is a position when the client is on their back but the head and trunk is raised to generally 30 to 45 degree angle (most commonly, a 30 degree angle).

  3. Semi-Fowler
    • Rationale:

      This answer is correct because one way to help reduce airway obstruction from edema of a person with a severe burn on the face and head is by elevating the client’s head to a semi-Fowler position. Severe burns to the face and head is a very serious concern related to the risk for edema in the airway that can cause airway obstruction. The priority intervention is to secure an airway and maintain that airway. The semi-Fowler position is a position when the client is on their back but the head and trunk is raised to generally 30 to 45 degree angle (most commonly, a 30 degree angle) and is the best positioning to reduce edema in the client.

  4. Side-lying
    • Rationale:

      This answer is not correct because the client with severe head and face edema would shift the edema to the side and could cause airway edema. The best choice to help reduce airway obstruction from edema is by elevating the client’s head to a semi-Fowler position. The semi-Fowler position is a position when the client is on their back but the head and trunk is raised to generally 30 to 45 degree angle (most commonly, a 30 degree angle).

       

Overview

The semi-Fowler position is the most appropriate position for a client with severe burns of the face and head to decrease edema in general, but most importantly, to prevent airway obstruction from edema.

Explanation

Learning Outcomes

Severe burns to the face and head is a very serious concern related to the risk for edema in the airway that can cause airway obstruction. The priority intervention is to secure an airway and maintain that airway. One way to help reduce airway obstruction from edema is by elevating the client’s head to a semi-Fowler position. The semi-Fowler position is a position when the client is on their back but the head and trunk is raised to generally 30 to 45 degree angle (most commonly, a 30 degree angle).

Test Taking Tip

If you have trouble remembering what supine is, think, “Supine on your spine”.

Video Rationale