Burns: Initial Resuscitation Priorities - NCLEX Rn

1. A 28-year-old client (history: none) presents after a bonfire accident with 20% TBSA partial-thickness burns to the arms and chest. Current assessment: alert; vital signs: T 37.0°C (98.6°F), HR 118/min, RR 20/min, BP 110/70 mm Hg, SpO2 98% on room air. The provider writes several orders. The nurse should question which order regarding initial resuscitation?
   Answer: Insert a nasogastric tube for low intermittent suction due to risk of ileus This question tests initial resuscitation priorities in burn care. It uses a clinical judgment framework to question inappropriate orders for moderate burns. Inserting a nasogastric tube is questionable for this stable 20% TBSA client without ileus signs, as it's unnecessary and risks complications, prioritizing evidence-based care. Starting IV fluids (A), administering morphine (B), and applying coverings (D) are appropriate for resuscitation and comfort. Principles reserve NG tubes for larger burns or gastrointestinal symptoms to prevent aspiration. Airway protection and pain control are key in initial phases. Question interventions lacking indications, using assessment data to guide necessity in burn management.
2. A 46-year-old client arrives 1 hour after a propane explosion with approximately 42% total body surface area partial- and full-thickness burns to the trunk and both legs. History includes hypertension; the client is alert and speaking in full sentences with no soot noted. Vital signs: T 36.5°C (97.7°F), HR 122/min, RR 22/min, BP 88/54 mm Hg, SpO2 98% on room air. Which intervention should the nurse prioritize for this burn client?
   Answer: Start two large-bore intravenous lines and begin warmed lactated Ringer solution using a burn resuscitation protocol This question tests initial resuscitation priorities in burn care, specifically addressing circulatory shock management in a large burn. The clinical judgment framework focuses on circulation priorities when airway and breathing are stable. The correct answer (A) represents the highest priority because the client has hypotension (88/54 mm Hg) and tachycardia (122/min) indicating hypovolemic shock from massive fluid shifts in a 42% TBSA burn, requiring immediate fluid resuscitation. Option B (pain management) is important but must wait until hemodynamic stability is achieved; option C (laboratory studies) would delay critical fluid therapy; option D (topical antimicrobials) is part of wound care but not an immediate priority during resuscitation. Burn resuscitation follows the principle that fluid losses begin immediately after injury, with plasma shifting into the interstitial space causing intravascular depletion. The Parkland formula or similar protocols guide initial fluid rates based on weight and burn size. A transferable strategy is to recognize that in burns >20% TBSA without airway compromise, establishing vascular access and beginning fluid resuscitation takes precedence over other interventions.
3. A 72-year-old client (history: chronic kidney disease stage 3 and coronary artery disease) arrives after a household chemical spill with deep burns to both hands and forearms; the client reports the chemical was a strong drain cleaner. Estimated 6% TBSA chemical burns with ongoing burning pain; vital signs: T 36.7°C (98.1°F), HR 104/min, RR 20/min, BP 158/84 mm Hg, SpO2 96% on room air. Which intervention should the nurse prioritize immediately?
   Answer: Begin copious irrigation of the affected areas with tepid running water after removing contaminated clothing and jewelry This question tests initial resuscitation priorities in burn care. It uses a safety and priority intervention framework for chemical burns, focusing on decontamination. Beginning copious irrigation after removing contaminated items is the highest priority to neutralize the chemical agent, stop ongoing tissue damage, and promote client safety. Applying occlusive dressings (B), requesting antibiotics (C), and elevating extremities (D) are incorrect or lower priorities, as dressings could trap chemicals, antibiotics are not immediate, and elevation follows decontamination. Key principles include immediate irrigation for chemical burns to minimize depth and extent, alongside airway protection if fumes are involved. Fluid management supports systemic stability but decontamination precedes it. Always prioritize stopping the burning process in chemical injuries by irrigating before addressing other needs.
4. A 45-year-old client (history: type 2 diabetes) presents to the emergency department 1 hour after a kitchen explosion with 40% TBSA partial- and full-thickness burns to the torso and both legs. Current assessment: alert but restless; burns are circumferential on the right leg; urine output has not yet been measured; vital signs: T 36.8°C (98.2°F), HR 122/min, RR 24/min, BP 94/58 mm Hg, SpO2 97% on 2 L/min nasal cannula. Which intervention should the nurse prioritize for this burn client?
   Answer: Start warmed lactated Ringer solution through two large-bore intravenous lines using a burn resuscitation protocol After a major burn, the immediate threat is hypovolemic shock from capillary leak. Tachycardia, hypotension, and restlessness indicate this is developing, so the priority is to start warmed lactated Ringer solution through two large-bore IV lines using a burn resuscitation protocol. Inserting a urinary catheter and beginning hourly urine output monitoring is an important later step, but it cannot restore circulating volume, and urine values have less meaning before fluid resuscitation is underway. Tetanus toxoid prophylaxis is standard burn care, but it is infection prevention and is not the first-hour life threat. Wound cultures from open burn areas are not urgently indicated; even with sterile technique, they do not treat shock and would not precede hemodynamic stabilization in the priority sequence. Airway is stable, so circulation is the focus.
5. A 34-year-old client is brought to the emergency department 30 minutes after a house fire with approximately 38% total body surface area partial- and full-thickness burns to the anterior chest, abdomen, and both arms. History includes asthma; the client is anxious with soot around the nares. Current assessment: hoarse voice and singed nasal hair; vital signs: T 36.8°C (98.2°F), HR 128/min, RR 30/min, BP 96/58 mm Hg, SpO2 92% on room air. What is the first action the nurse should take upon assessing the client?
   Answer: Apply a nonrebreather mask at 15 L/min and prepare for early endotracheal intubation This question tests initial resuscitation priorities in burn care, specifically recognizing and managing inhalation injury. The clinical judgment framework here follows the ABCs (Airway, Breathing, Circulation), with airway always being the highest priority. The correct answer (B) represents the highest priority because the client shows multiple signs of inhalation injury including hoarse voice, singed nasal hair, soot around nares, and low oxygen saturation, all indicating impending airway compromise that requires immediate intervention. Option A (urinary catheter) is important for monitoring fluid resuscitation but comes after securing the airway; option C (dry dressings) addresses heat loss but is a lower priority than airway management; option D (IV fluids) is critical for burn resuscitation but must follow airway stabilization. In burn resuscitation, early recognition of inhalation injury is crucial because airway edema can progress rapidly, making intubation difficult or impossible if delayed. The presence of facial burns, hoarseness, and carbonaceous sputum are red flags that mandate immediate airway protection. A transferable strategy for prioritizing burn care is to always assess for inhalation injury first, as airway compromise is the leading cause of early death in burn patients.
6. A 49-year-old client (history: none) arrives 45 minutes after a gasoline fire with 35% TBSA partial- and full-thickness burns to the chest, abdomen, and both arms. Current assessment: alert; no soot noted; vital signs: T 36.7°C (98.1°F), HR 126/min, RR 22/min, BP 92/60 mm Hg, SpO2 98% on room air. Which intervention should the nurse prioritize first?
   Answer: Establish two large-bore intravenous lines and start warmed isotonic crystalloid fluids per protocol This patient shows signs of hypovolemic shock from major burns (tachycardia, hypotension). The immediate priority is to restore circulating volume by establishing large-bore IV access and starting warmed isotonic crystalloids per protocol. Airway is already protected (alert, no soot, SpO2 98%), so circulation is the focus. High-calorie enteral nutrition is important but should begin after hemodynamic stability is achieved. Debridement of blisters is not done during initial resuscitation because intact blisters protect against infection and fluid loss. Likewise, applying antimicrobial dressings is a later wound-care step; the patient must be stabilized first. Thus, the best first intervention is fluid resuscitation via large-bore IV lines.
7. A 34-year-old client (history: none) has 36% TBSA partial- and full-thickness burns to the abdomen and both thighs from a camping fuel explosion. Current assessment: anxious, cool clammy skin; vital signs: T 36.6°C (97.9°F), HR 124/min, RR 20/min, BP 90/52 mm Hg, SpO2 98% on 2 L/min nasal cannula. The provider writes several orders. The nurse should question which order regarding the resuscitation plan?
   Answer: Administer furosemide intravenously now to increase urine output during the first 8 hours This question tests initial resuscitation priorities in burn care. It employs a clinical judgment framework to identify inappropriate orders in hypovolemic states. Administering furosemide is questionable as it could worsen hypovolemia in this tachycardic, hypotensive client, where fluid resuscitation is needed instead for safety. Inserting a catheter (A), starting fluids (B), and maintaining warmth (D) are appropriate for monitoring and preventing hypothermia. Principles emphasize crystalloid fluids to restore volume, avoiding diuretics that deplete it further. Airway protection and temperature control are key, but fluid overload is rare early on. Question orders that contradict hypovolemia management, applying evidence-based protocols for burns.
8. A 27-year-old construction worker is brought to the emergency department after an electrical injury from a high-voltage line. The client has small entry and exit wounds on the right hand and left foot and reports muscle pain; history is unremarkable. Assessment: irregular pulse noted on palpation; vital signs: T 37.0°C (98.6°F), HR 52/min and irregular, RR 18/min, BP 102/64 mm Hg, SpO2 99% on room air. Which intervention should the nurse prioritize for this burn client?
   Answer: Initiate continuous cardiac monitoring and obtain a 12-lead electrocardiogram This question tests initial resuscitation priorities in burn care, specifically recognizing cardiac complications from electrical injury. The clinical judgment framework prioritizes life-threatening cardiac dysrhythmias in electrical burns. The correct answer (B) represents the highest priority because electrical injuries can cause immediate cardiac dysrhythmias (evidenced by irregular pulse and bradycardia at 52/min), which can deteriorate to lethal rhythms without warning. Option A (surgical debridement) is premature and not immediately indicated; option C (ice packs) is contraindicated as it can worsen tissue damage; option D (pain history) delays critical cardiac monitoring. Electrical burns are unique because the visible skin damage often underestimates internal injury, and cardiac effects can be immediate or delayed. High-voltage injuries frequently cause cardiac dysrhythmias due to disruption of the heart's electrical conduction system. A transferable strategy is to recognize that any electrical injury requires immediate cardiac monitoring as the first priority, regardless of the apparent severity of external burns.
9. A 44-year-old client (history: none) arrives 2 hours after a warehouse fire with 42% TBSA partial- and full-thickness burns to the torso and both legs. Current assessment: restless; peripheral pulses weak; vital signs: T 36.3°C (97.3°F), HR 138/min, RR 26/min, BP 82/48 mm Hg, SpO2 96% on 4 L/min nasal cannula. Which intervention should the nurse prioritize first to address circulation?
   Answer: Start a second large-bore intravenous line and rapidly infuse warmed isotonic crystalloid per protocol This question tests initial resuscitation priorities in burn care. It utilizes a circulation-focused framework for addressing hypovolemic shock in major burns. Starting a second IV line and rapidly infusing warmed crystalloids is the highest priority to restore volume in this restless, hypotensive client, ensuring perfusion and safety. Administering albumin (B), obtaining labs first (C), and elevating the bed (D) are incorrect, as albumin is not first-line and delays are risky. Principles advocate large-volume crystalloids per formulas to counter fluid shifts. Airway protection supports resuscitation but circulation is the focus. Escalate fluid rates based on vital signs, using protocols for timely shock reversal.
10. A 68-year-old client is brought to the emergency department 45 minutes after a kitchen fire with approximately 28% total body surface area full-thickness burns to the right arm and partial-thickness burns to the anterior torso. History includes coronary artery disease and heart failure with reduced ejection fraction. Assessment: cool, pale skin and delayed capillary refill; vital signs: T 36.6°C (97.9°F), HR 124/min, RR 22/min, BP 84/50 mm Hg, SpO2 96% on room air. Which intervention should the nurse prioritize for this burn client?
    Answer: Start warmed isotonic intravenous fluids and closely monitor response (blood pressure and urine output) This question tests initial resuscitation priorities in burn care, specifically managing burns in patients with cardiac comorbidities. The clinical judgment framework balances urgent fluid needs against cardiac limitations. The correct answer (A) represents the highest priority because despite the heart failure history, the client is in hypovolemic shock (BP 84/50, tachycardia, cool skin) from the 28% TBSA burn and requires careful fluid resuscitation with close monitoring. Option B (restricting fluids) would worsen shock and organ perfusion; option C (delaying for central line) postpones critical treatment; option D (prone positioning) is inappropriate and doesn't address shock. Burn patients with cardiac disease require modified but not withheld fluid resuscitation, using careful titration based on hemodynamic response. The key is balancing adequate perfusion against fluid overload risk through frequent reassessment. A transferable strategy is to recognize that even patients with heart failure need fluid resuscitation for burn shock, but require more frequent monitoring and careful titration based on response.
11. A 52-year-old client (history: alcohol use disorder) presents 2 hours after a garage fire with 28% TBSA partial- and full-thickness burns to the back and posterior legs. Current assessment: awake, thirsty, capillary refill delayed; vital signs: T 36.5°C (97.7°F), HR 132/min, RR 22/min, BP 88/54 mm Hg, SpO2 95% on 2 L/min nasal cannula. Which intervention should the nurse prioritize to evaluate adequacy of fluid resuscitation?
    Answer: Insert an indwelling urinary catheter and monitor urine output hourly This question tests initial resuscitation priorities in burn care. It applies a priority intervention framework for evaluating fluid resuscitation efficacy. Inserting an indwelling urinary catheter for hourly output monitoring is the highest priority to assess resuscitation adequacy, as low output indicates hypovolemia in this tachycardic, hypotensive client, promoting safety through guided fluid adjustments. Measuring wound size (A), obtaining daily weights (C), and auscultating bowel sounds (D) are lower priorities, as they do not directly evaluate acute fluid status like urine output does. Burn resuscitation principles underscore urine output as a key indicator of perfusion, targeting 0.5-1 mL/kg/hr in adults. Airway protection and fluid balance are foundational to prevent complications like acute kidney injury. In similar situations, prioritize objective monitoring tools like urine output to titrate interventions effectively.
12. A 36-year-old client (history: none) arrives after a flame burn with 33% TBSA partial- and full-thickness burns to the chest, abdomen, and both arms. Current assessment: alert; vital signs: T 36.8°C (98.2°F), HR 124/min, RR 22/min, BP 100/62 mm Hg, SpO2 97% on 2 L/min nasal cannula. Which nursing action best supports initial burn resuscitation priorities?
    Answer: Start isotonic intravenous fluids via large-bore access and titrate based on urine output and vital signs The most urgent problem in this client is hypovolemia from a 33% TBSA burn, shown by tachycardia and borderline low blood pressure. Starting an isotonic crystalloid through large-bore IV access and titrating it to urine output and vital signs supports perfusion and is the correct first action. Delaying fluids until transfer so the receiving team can set the rate is unsafe because fluid loss continues during transport and hypotension can worsen. Applying ice packs directly to burned areas and keeping them in place may cause vasoconstriction and additional tissue injury; it also does not restore circulating volume. Giving prophylactic antibiotics within the first 24 hours targets infection, not the immediate threat of inadequate perfusion, and routine prophylactic antibiotics are not recommended. Therefore, crystalloid resuscitation begun immediately and adjusted by ongoing assessment is the best initial priority.
13. A 41-year-old client (history: asthma) arrives after a flash burn from lighter fluid with 22% TBSA partial-thickness burns to the face, neck, and upper chest. The client is speaking in full sentences but has progressive hoarseness and frequent coughing; vital signs: T 37.0°C (98.6°F), HR 118/min, RR 26/min, BP 128/76 mm Hg, SpO2 94% on room air. Which finding requires immediate intervention by the nurse?
    Answer: Hoarseness and coughing that are worsening over time This question tests initial resuscitation priorities in burn care. It utilizes a safety framework to identify urgent signs of deterioration. Hoarseness and worsening coughing require immediate intervention as they signal progressive airway compromise from inhalation injury, prioritizing client safety to prevent obstruction. Severe pain (B), partial-thickness burns (C), and tachycardia (D) are expected but lower priorities, as pain management and stress responses follow airway assessment. Principles include vigilant monitoring for inhalation injury signs like hoarseness, which can rapidly progress to edema. Fluid management supports overall resuscitation but airway protection is paramount. Always escalate care for subtle airway changes in facial burns using ABCs for prioritization.
14. A 29-year-old client (history: none) is brought in after an electrical injury at a construction site; there are small full-thickness burns on the right hand and left foot (suspected entry/exit wounds), and the client reports chest tightness. Vital signs: T 36.9°C (98.4°F), HR 56/min and irregular, RR 18/min, BP 102/66 mm Hg, SpO2 98% on room air. Which intervention should the nurse prioritize?
    Answer: Initiate continuous cardiac monitoring and obtain a 12-lead electrocardiogram This question tests initial resuscitation priorities in burn care. It incorporates the ABC framework with emphasis on circulation and cardiac monitoring in electrical injuries. Initiating continuous cardiac monitoring and obtaining an ECG is the highest priority due to risks of arrhythmias from electrical current, evidenced by irregular heart rate and chest tightness, ensuring early detection for client safety. Applying dressings (A), starting oral fluids (C), and assessing tetanus (D) are lower priorities, as wound care and prophylaxis follow cardiac stabilization. Principles of burn resuscitation for electrical injuries stress monitoring for internal damage beyond visible burns, including cardiac and neurological effects. Fluid management is vital but secondary to arrhythmia risks. Use a systematic approach like ABCs extended to include dysrhythmia surveillance in electrical burns for timely interventions.
15. A 57-year-old client (history: peripheral vascular disease) has circumferential full-thickness burns to the left forearm and hand after a propane explosion; estimated 9% TBSA. The extremity is cool with delayed capillary refill; the client reports increasing numbness. Vital signs: T 36.8°C (98.2°F), HR 108/min, RR 20/min, BP 134/80 mm Hg, SpO2 96% on room air. Which finding requires immediate intervention by the nurse?
    Answer: Increasing numbness and coolness distal to a circumferential burn This question tests initial resuscitation priorities in burn care. It applies a safety framework to identify compartment syndrome risks. Increasing numbness and coolness distal to circumferential burns require immediate intervention, signaling vascular compromise needing escharotomy for limb salvage and safety. Tachycardia (B), burn size (C), and family requests (D) are lower priorities, not indicating acute ischemia. Principles include frequent neurovascular checks in circumferential burns to detect edema-induced compression early. Fluid management is essential but monitoring prevents complications like amputation. Prioritize escharotomy readiness in limb burns by assessing distal perfusion routinely.
16. A 5-year-old child (history: none) is brought in after spilling hot tea on the face and neck; estimated 10% TBSA partial-thickness scald burns. The child has audible wheezing and increasing work of breathing; vital signs: T 37.4°C (99.3°F), HR 156/min, RR 38/min, BP 90/54 mm Hg, SpO2 89% on room air. Which intervention should the nurse prioritize?
    Answer: Provide humidified oxygen and prepare for escalation of airway support This question tests initial resuscitation priorities in burn care. It employs the ABC framework, prioritizing airway and breathing in pediatric facial burns. Providing humidified oxygen and preparing for airway support is the highest priority for wheezing and hypoxia, indicating edema risk, to prevent failure and ensure safety. Starting fluids (A), applying ointment (C), and covering burns (D) are lower priorities, as airway precedes them. Principles note children's proneness to rapid airway compromise in facial scalds. Fluid management is crucial but secondary to oxygenation. Always address respiratory distress first in pediatric burns using ABCs for escalation.
17. A 38-year-old client (history: hypertension) arrives 30 minutes after a house fire with approximately 32% total body surface area (TBSA) partial- and full-thickness burns to the anterior chest, abdomen, and both arms; soot is noted around the nares and the client is hoarse with singed nasal hairs. Current assessment: anxious, audible stridor; vital signs: T 37.2°C (99.0°F), HR 128/min, RR 30/min, BP 146/88 mm Hg, SpO2 92% on room air. What is the first action the nurse should take upon assessing the client?
    Answer: Prepare for early endotracheal intubation and notify the provider/rapid response team of impending airway compromise This question tests initial resuscitation priorities in burn care. It utilizes the ABC clinical judgment framework, emphasizing airway, breathing, and circulation. Preparing for early endotracheal intubation and notifying the provider represents the highest priority because signs of inhalation injury, such as hoarseness, stridor, singed nasal hairs, and soot, indicate impending airway compromise that could lead to rapid deterioration and client safety risks. Inserting IV catheters and starting fluids (A), obtaining weight for fluid calculation (C), and applying antimicrobial cream (D) are important but lower priorities compared to securing the airway, as fluid resuscitation and wound care can follow airway stabilization. In burn resuscitation, protecting the airway is critical due to the risk of edema and obstruction from inhalation injuries. Fluid management is essential to prevent hypovolemic shock, but it must not delay airway interventions. When prioritizing care in burn scenarios, always apply the ABC framework to address life-threatening issues first, such as airway patency before circulation or wound management.
18. A 33-year-old client presents after being trapped briefly in a burning apartment with approximately 20% total body surface area partial-thickness burns to the face and neck. History includes no chronic illness; assessment shows carbonaceous sputum and mild confusion. Vital signs: T 37.0°C (98.6°F), HR 110/min, RR 24/min, BP 118/74 mm Hg, SpO2 100% on room air. Which intervention should the nurse prioritize for this burn client?
    Answer: Administer 100% oxygen via nonrebreather mask and notify the provider of suspected carbon monoxide exposure This question tests initial resuscitation priorities in burn care, specifically recognizing carbon monoxide poisoning. The clinical judgment framework involves identifying life-threatening toxic exposures that may not be apparent through routine vital signs. The correct answer (B) represents the highest priority because the client shows classic signs of carbon monoxide poisoning (confusion, carbonaceous sputum, history of entrapment) despite normal SpO2, as pulse oximetry cannot differentiate between oxyhemoglobin and carboxyhemoglobin. Option A (reassurance) ignores critical signs of CO poisoning; option C (incentive spirometry) doesn't address the toxic exposure; option D (topical antibiotics) is not the immediate priority. Carbon monoxide poisoning is a major cause of death in fire victims, and normal oxygen saturation readings are falsely reassuring because standard pulse oximetry cannot detect carboxyhemoglobin. High-flow oxygen is the immediate treatment to displace CO from hemoglobin. A transferable strategy is to recognize that any fire victim with altered mental status or carbonaceous sputum requires immediate high-flow oxygen regardless of pulse oximetry readings.
19. A 40-year-old client (history: none) arrives after a house fire with 25% TBSA partial-thickness burns to the arms and upper back. The client is confused and has a headache; there is soot in the mouth. Vital signs: T 37.1°C (98.8°F), HR 112/min, RR 24/min, BP 124/72 mm Hg, SpO2 99% on a nonrebreather mask. Which intervention should the nurse prioritize based on the assessment?
    Answer: Request an order for carboxyhemoglobin level and continue high-flow oxygen therapy The client has confusion, headache, and soot in the mouth after a house fire, which are indicators of carbon monoxide poisoning even when a standard pulse oximetry reading is 99%. Carbon monoxide binds to hemoglobin and reduces oxygen-carrying capacity without necessarily lowering the measured SpO2, so the nurse is required to continue high-flow oxygen and request a carboxyhemoglobin level. Titrating the oxygen down to room air is dangerous because a normal SpO2 does not rule out carbon monoxide toxicity and lowering oxygen delays CO elimination. Providing oral fluids does not address the oxygen-carrying problem and is unsafe for a confused client; if fluid replacement is needed, it should be intravenous. Applying topical antimicrobial cream and beginning wound care are important later in burn management, but they do not take priority over treating possible inhalation injury. Therefore, continue high-flow oxygen and obtain the carboxyhemoglobin level.
20. A 3-year-old child (history: none) has 12% TBSA partial-thickness scald burns to the anterior torso and left arm from hot bath water. The child is lethargic and has weak peripheral pulses; vital signs: T 36.4°C (97.5°F), HR 168/min, RR 32/min, BP 78/44 mm Hg, SpO2 97% on room air. Which intervention should the nurse prioritize?
    Answer: Cover the burns with clean dry sheets to reduce heat loss while initiating intravenous access for fluid resuscitation This question tests initial resuscitation priorities in burn care. It uses the ABC framework, focusing on circulation in hypovolemic pediatric burns. Covering burns with clean dry sheets while initiating IV access for fluids is the highest priority to minimize heat loss and address shock signs like lethargy and weak pulses, enhancing safety. Applying ointment (B), offering oral fluids (C), and delaying for history (D) are lower priorities or unsafe, as oral intake risks aspiration and history follows stabilization. Principles stress rapid fluid initiation in children due to higher surface area ratios leading to quick dehydration. Airway protection is vital, but here circulation and thermoregulation are immediate. Prioritize stabilizing vital signs in pediatric burns before detailed assessments.

Start this quiz