A male client who weighs 90 kg is admitted to the emergency department with full thickness burns to 45% of his total body surface area (TBSA). The burns occurred at 1000. At 1200, the nurse uses the prescribed protocol for burns fluid resuscitation to calculate the total fluid volume for the first 24 hours. The infusion pump should be set to deliver how many mL/hour during the first 8 hours? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
The Correct Answer is ["1350"]
Rationale:
Fluid resuscitation rate using the Parkland formula:
- Calculate the total fluid volume needed for the first 24 hours.
The Parkland formula: 4 mL × client weight (kg) × % TBSA burned.
Client weight = 90 kg
TBSA burned = 45%
Total fluid volume = 4 mL × 90 kg × 45 = 16,200 mL
- Determine the amount of fluid to be given in the first 8 hours.
According to the Parkland formula, half of the total fluid volume is administered in the first 8 hours from the time of the burn injury.
Fluid for first 8 hours = 16,200 mL / 2
= 8,100 mL
- Calculate the infusion rate for the first 8 hours.
The burn occurred at 1000. The nurse arrives at 1200. This means 2 hours have already passed since the burn occurred within the initial 8-hour period.
Remaining time in the first 8 hours = 8 hours - 2 hours
= 6 hours.
Infusion rate (mL/hour) = Fluid for remaining first 8 hours / Remaining time in first 8 hours
= 8,100 mL / 6 hours
= 1350 mL/hour.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. "Hyperglycemia often results in weight loss." While chronic uncontrolled hyperglycemia, particularly in Type 1 diabetes, can lead to weight loss due to the body breaking down fat and muscle for energy, this is less typical for the acute or early signs of hyperglycemia.
B. "Hyperglycemia often presents as increased thirst and urination." This is a classic symptom of hyperglycemia, polydipsia (increased thirst) and polyuria (increased urination), caused by the body attempting to eliminate excess glucose through urine.
C. "Hyperglycemia causes an increased sensation of being hungry." Hyperglycemia can cause an increased sensation of hunger (polyphagia), which occurs due to insulin resistance or the body’s inability to use glucose properly.
D. "Hyperglycemia causes a headache and flushed, dry skin." A common symptom of hyperglycemia is headache, and flushed, dry skin can occur due to dehydration from excessive urination.
E. "Hyperglycemia causes cool and clammy skin." Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia. Hyperglycemia usually presents with warm, dry skin due to dehydration.
Correct Answer is ["C","D","E","G","H"]
Explanation
A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.
B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.
C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.
D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.
E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.
F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.
G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.
H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.
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