Practice Question
A nurse is caring for a client in an emergency department.
Answer Choices:
Rationale:
💧 Fluid Resuscitation
🔷 Explanation of Priority: After an extensive burn injury involving 30% of the total body surface area (TBSA), the body experiences a massive fluid and electrolyte shift from the intravascular space into the interstitial and intracellular compartments. This results in burn shock if not promptly treated.
🔷 Pathophysiology: Thermal injury increases capillary permeability, allowing plasma, proteins, and sodium to leak out of circulation, leading to edema, decreased blood volume, and reduced cardiac output.
🔷 Clinical Significance: The client’s tachycardia (127/min) and burns covering 30% TBSA indicate an early hypovolemic response even before hypotension occurs. Without rapid replacement, the client is at risk for organ hypoperfusion and shock.
🔷 Nursing Action: The nurse should initiate fluid resuscitation using the Parkland formula (4 mL × body weight in kg × %TBSA burned). Half of this volume should be infused during the first 8 hours post-injury, and the remaining half over the next 16 hours.
🔷 Goal of Therapy: Maintain urine output of 30–50 mL/hr, stable vital signs, and adequate tissue perfusion to prevent complications like acute kidney injury and multi-organ failure.
💦 Risk for Hypovolemia
💠 Reason for Priority: Burns greater than 20% TBSA cause significant plasma loss through damaged capillaries, resulting in hypovolemia. This fluid loss can lead to decreased cardiac output and tissue hypoxia if not replaced aggressively.
💠 Physiological Evidence: Early symptoms include tachycardia, anxiety, cool skin, and decreased urine output; blood pressure may initially remain normal before dropping as volume loss continues.
💠 Priority Rationale: Preventing hypovolemia takes precedence over dressing wounds or infection prevention in the emergent (resuscitative) phase of burn management, as circulatory collapse is the most immediate threat to life.
💠 Ongoing Monitoring: Nurses must continuously monitor vital signs, urine output, central venous pressure (if available), and mental status to assess response to fluids.
💠 Expected Outcome: Effective fluid resuscitation stabilizes circulation, ensuring adequate organ perfusion and preventing burn shock.
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This question is from RN Concept Based Level Assessment 4 which contains 140 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Concept-Based Assessment Level Exam(s)
- Answer Choices: 0