Example Care Plan_Burn Injury (First, Second, Third degree)

A 28-year-old woman is admitted to the ED after a house fire. She has second- and third-degree burns over approximately 30% of her body-surface area, including her face. Endotracheal intubation is performed, and IV lines are established. The goals of IV therapy for this patient would be based on all of the following except:

Which statement best describes the rationale for keeping a patient from ingesting food or liquids (NPO status) while in the ED after a burn?

During the later stages (after the first 3 days) of a burn injury, the nurse would expect the patient to show signs of:

An adult patient has partial-thickness and full-thickness burns over one half the anterior chest and abdomen, the perineal area, and the anterior aspect of both legs and feet. Based on the Rule of Nines, the closest estimate of total body-surface area (BSA) involved would be:

Which parameter is commonly used as a guideline for adequate fluid replacement?

The nurse recognizes which IV fluid will best treat the acidosis associated with a burn injury?

The phases of burn injury are emergent/resuscitation/burn shock, acute, and rehabilitative. During the acute phase of a burn injury, the capillaries seal and electrolytes remobilize with the fluid. At this time, the nurse should assess the laboratory results for:

Admission assessment of a 54.4 kg patient shows partialthickness and full-thickness burns over one half the back, the perineal area, and the posterior aspect of both legs and feet. Based on the standard fluid replacement formula, what is the maximum fluid the patient will receive over the first 24 hours based on this presentation?

A patient has been burned to the following areas: Anterior right leg-superficial partial thickness, entire left leg-superficial and partial thickness, and anterior chest-partial thickness. Using the rule of 9s, which of the follow is the total surface area burned?

After ensuring airway patency, obtaining baseline vitalsigns, and establishing an IV of Lactated Ringer’s solution, the patient’s condition stabilizes. Because airway obstruction may still occur, the nurse must assess frequently for airway patency. How long after injury should frequent airway assessments be made?

A burn ICU nurse receives a new admission with burns over 30% of the body. The client is sedated, receiving IV pain medication, and edematous. Which of the following is the nurse’s main concern?

A client with burns over 36% of the body is admitted to the burn unit. The nurse immediately checks for IV patency, and searches for a secondary IV site with the intent to start a second large-bore IV. Why?