NR341 Week 4 & 5

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, at what rate would the nurse infuse the IV fluids?

• 219 mL/hr

• 625 mL/hr

• 938 mL/hr

Answer explanation

Half of the fluid replacement using the Parkland formula is administered in the first 8 hours, and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer‘s solution that the nurse will give during the first 8 hours?

____ mL

Answer explanation

600 mL

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The Parkland formula states that patients should receive 4 mL/kg/% TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours, and then the remaining half is given over 16 hours: 4 X 80 X 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured? ___ %

Answer explanation

27%

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When using the rule of nines, the anterior trunk is considered to cover 18% of the patient‘s body, and the anterior (4.5%) and posterior (4.5%) left arm equals 9%.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. Which term would the nurse use to document the burn depth?

• First-degree skin destruction

• Full-thickness skin destruction

• Superficial partial-thickness skin destruction

Answer explanation

Full-thickness skin destruction

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With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction.

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Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present.

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First-degree burns exhibit erythema, blanching, and pain.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K⁺ 4.9 mEq/L (4.8 mmol/L), and serum Na⁺ 135 mEq/L (135 mmol/L). Which prescribed action would be the nurse’s priority?

• Monitoring urine output

• Scheduling additional laboratory tests

• Increasing the rate of the ordered IV solution

• Typing and crossmatching for a blood transfusion

Answer explanation

Increasing the rate of the ordered IV solution

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The patient‘s laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Additional lab tests can be scheduled after the fluid volume is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient‘s fluid balance has been restored. Urine output would be monitored frequently, likely every hour, and adequate fluid volume will be needed to maintain the urine output.

During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluids?

• Check skin turgor.

• Monitor daily weight.

• Assess mucous membranes.

• Measure hourly urine output.

Answer explanation

Measure hourly urine output.

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When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient’s weight is not as useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as useful in determining that fluid infusions are maintaining adequate perfusion.

A patient admitted with burns over 30% of the body surface 3 days ago has dramatically increased urine output today. How would the nurse interpret this finding?

• Diuresis indicates development of acute kidney injury.

• Diuresis reflects normalizing capillary permeability.

• Increased urine volume signals a likely urinary infection.

• Increased urine volume requires increased calorie intake.

Answer explanation

Diuresis reflects normalizing capillary permeability.

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At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. This usually happens about 72 hours after the initial injury. A low urine output in the early days after a burn injury would raise concern for possible kidney injury form hypovolemia. Patients with burns are susceptible to infection and may need additional calories for wound healing. However, increased urine volume is not associated with a urinary tract infection or a need for additional calories.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would the nurse recommend as providing the most support for wound healing?

• Banana

• Orange gelatin

• Vanilla milkshake

• Whole grain bagel

Answer explanation

Vanilla milkshake

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A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients. the other choices are not as nutrient-dense as the milkshake. Gelatin is high in sugar. The bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. Which assessment is the priority?

• Oral temperature

• Peripheral pulses

• Extremity movement

• Pupil reaction to light

Answer explanation

Extremity movement

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All patients with electrical burns would be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are necessary but not as essential as determining the cervical spine status.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action would the nurse take first?

• Stay at the bedside and reassure the patient. at the bedside

• Administer the ordered morphine sulfate IV.

• Assess orientation and level of consciousness.

• Use pulse oximetry to check oxygen saturation.

Answer explanation

Use pulse oximetry to check oxygen saturation.

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Agitation in a patient who may have suffered an inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing the level of consciousness and orientation is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.