A client presents with a partial-thickness burn covering 20% of their total body surface area (TBSA) after an industrial accident. What is the most appropriate initial action by the nurse to manage fluid resuscitation for this client?

Start administering 1000 mg of Vancomycin IV immediately to prevent infection.

Administer 4 mL of lactated Ringer's solution IV per kg of body weight per TBSA.

Provide oral fluids until the client is stable.

Wait for 24 hours before starting any fluid resuscitation.

Answer and Explanation

The Correct Answer is B

Major burn injuries involving a significant total body surface area (TBSA) trigger a profound inflammatory response that leads to increased capillary permeability and massive fluid shifts from the intravascular space into the interstitial space. This results in hypovolemic shock if not promptly managed. Fluid resuscitation is therefore a critical early intervention to maintain tissue perfusion and organ function. Standardized formulas guide initial fluid replacement in burn management.

Rationale:
A. Starting IV vancomycin immediately to prevent infection is not the priority in the acute phase of burn management. Although infection prevention is important in burn care, fluid resuscitation takes precedence in the initial management to prevent hypovolemic shock. Antibiotics are not routinely given prophylactically unless there is evidence of infection.

B. Administering 4 mL of lactated Ringer’s solution IV per kg of body weight per TBSA is correct because it follows the Parkland formula for burn resuscitation. Parkland formula guides initial fluid replacement to restore circulating volume and maintain organ perfusion. Lactated Ringer’s is preferred because it closely resembles extracellular fluid and helps correct metabolic acidosis associated with burns.

C. Providing oral fluids until the client is stable is inappropriate for a client with a 20% TBSA burn. Oral intake is insufficient to meet the rapid and large fluid losses caused by capillary leakage in moderate to severe burns. Intravenous fluid resuscitation is required to prevent shock and maintain hemodynamic stability.

D. Waiting 24 hours before starting fluid resuscitation is dangerous and can result in severe hypovolemic shock and organ failure. Fluid resuscitation must begin immediately after burn assessment to counteract fluid shifts that occur within the first several hours. Delaying treatment significantly increases mortality risk in major burn injuries.

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Correct Answer is ["C","D","E"]

Explanation

Increased intracranial pressure (ICP) following a closed-head injury occurs when brain swelling, bleeding, or impaired cerebrospinal fluid dynamics raise pressure within the rigid skull. This can compromise cerebral perfusion and lead to secondary brain injury if not managed promptly. Nursing interventions focus on reducing stimuli that elevate ICP, maintaining adequate cerebral perfusion, and closely monitoring neurological status for early signs of deterioration.

Rationale:
A. Suctioning the endotracheal tube frequently is not recommended because it can significantly increase intracranial pressure. Suctioning stimulates coughing and vagal responses, which elevate intrathoracic pressure and subsequently reduce venous return from the brain. It should only be performed when necessary and with preoxygenation and careful technique.

B. Positioning the client in high Fowler’s position is inappropriate for managing increased ICP. Excessive elevation may reduce cerebral perfusion pressure in some clients. The optimal position is typically head-of-bed elevation around 30 degrees with neutral head alignment to promote venous drainage without compromising blood flow to the brain.

C. Administering a stool softener is important because straining during defecation increases intrathoracic and intracranial pressure through the Valsalva maneuver. Preventing constipation reduces the risk of sudden ICP spikes. Stool softeners help maintain regular, strain-free bowel movements, supporting stable intracranial dynamics.

D. Performing frequent neurological assessments is essential for early detection of changes in intracranial pressure. Monitoring level of consciousness, pupil response, and motor function helps identify deterioration before irreversible brain damage occurs. Timely recognition allows for rapid intervention to prevent further neurological decline.

E. Decreasing the noise level in the client’s room helps reduce external stimulation that can elevate intracranial pressure. Environmental stimuli such as loud noise, bright lights, and excessive activity can increase cerebral metabolic demand. A calm, low-stimulation environment supports brain rest and helps stabilize ICP.

A. Delay rehabilitation assessments until after discharge B. Reevaluate antithrombotic therapy on hospital day 2 C. Document stroke education for the client D. Increase the dosage of anticoagulants immediately E. Provide VTE prophylaxis F. Administer thrombolytic therapy as indicated

Correct Answer is ["B","C","E","F"]

Explanation

Acute stroke management follows evidence-based core measures aimed at improving outcomes, reducing complications, and preventing recurrence. These measures include timely reperfusion therapy, prevention of venous thromboembolism (VTE), appropriate antithrombotic management, and patient education. Early implementation of standardized stroke protocols improves survival and functional recovery. Nursing care plays a central role in ensuring adherence to these time-sensitive and guideline-driven interventions.

Rationale:
A. Delaying rehabilitation assessments until after discharge is incorrect because early rehabilitation evaluation is an essential component of stroke care. Early mobilization and assessment help reduce complications such as contractures, pressure injuries, and functional decline. Rehabilitation planning begins during hospitalization to improve recovery outcomes.

B. Reevaluating antithrombotic therapy on hospital day 2 is appropriate because stroke management includes reassessment of antiplatelet or anticoagulant therapy based on stroke type and clinical progression. This ensures optimal prevention of recurrent cerebrovascular events while balancing bleeding risk. Adjustments are made according to diagnostic findings and patient response.

C. Documenting stroke education for the client is a core measure because patient and family education is essential for secondary prevention. Education includes risk factor modification, medication adherence, and recognition of stroke warning signs. Proper documentation ensures continuity of care and confirms that discharge teaching has been completed.

D. Increasing the dosage of anticoagulants immediately is not a core stroke measure and may be unsafe without proper evaluation. Anticoagulant therapy must be carefully individualized based on stroke type (ischemic vs hemorrhagic) and bleeding risk. Empiric dose escalation could increase the risk of intracranial hemorrhage.

E. Providing VTE prophylaxis is a key core measure because stroke clients are at high risk for immobility-related complications such as deep vein thrombosis and pulmonary embolism. Interventions may include pharmacologic prophylaxis (e.g., low-dose heparin) and mechanical devices like sequential compression devices. This reduces morbidity and mortality during hospitalization.

F. Administering thrombolytic therapy as indicated is a critical acute stroke intervention for eligible clients with ischemic stroke. Timely administration of thrombolytics such as tissue plasminogen activator (tPA) can restore cerebral perfusion and minimize neurologic damage. This treatment must be given within a strict therapeutic time window and after exclusion of hemorrhagic stroke.

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A client presents with a partial-thickness burn covering 20% of their total body surface area (TBSA) after an industrial accident. What is the most appropriate initial action by the nurse to manage fluid resuscitation for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following actions should the nurse take to manage increased intracranial pressure (ICP) for a client with a closed-head injury? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

Which of the following core measures should the nurse implement for a client experiencing an acute stroke? Select four that apply.

Correct Answer is ["B","C","E","F"]

Explanation

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