Practice Question
A client with burns over 25% of their total body surface area is admitted. What is the nurse's priority in the first 24 hours?
Answer Choices:
Correct Answer:
Managing fluid resuscitation to prevent shock.
Rationale:
🟦 In the first 24 hours after a major burn, the greatest threat to life is hypovolemic shock caused by massive fluid shifts and capillary leakage.
🟦 Burns involving more than 20–25% total body surface area lead to rapid loss of intravascular volume into interstitial spaces.
🟦 Aggressive fluid resuscitation (commonly guided by the Parkland formula) is essential to maintain adequate tissue perfusion and organ function.
🟦 Urine output, vital signs, and hemodynamic status are closely monitored to evaluate the effectiveness of resuscitation.
🟦 Stabilizing circulation is the highest priority in the emergent phase, before wound care, nutrition, or infection prevention.
Performing debridement of burn wounds.
🟦 Debridement is important for wound healing but is not the immediate priority in the first 24 hours.
🟦 It is typically performed after the client is hemodynamically stable.
Providing nutritional support to aid healing.
🟦 Nutritional support is essential due to the hypermetabolic state caused by burns.
🟦 However, it becomes a priority after initial fluid resuscitation and stabilization.
Administering broad-spectrum antibiotics.
🟦 Prophylactic antibiotics are not routinely given in the immediate burn phase.
🟦 Infection prevention focuses first on aseptic technique and wound care, not early antibiotics.
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This question is from RN NTEGUMENTARY which contains 46 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Fundamentals
- Answer Choices: 4