A nurse in an emergency department is caring for a 118.8-lb client who sustained burn injuries in a grease fire. The nurse documents the burnt surface areas in the accompanying diagram and starts an infusion of lactated Ringers at 2300 hours. Using the Rule of Nines, what is the rate of infusion of lactated Ringers at 0600 hrs?
213 mL/hr
152 mL/hr
425 mL/hr
284 mL/hr
The Correct Answer is C
- Calculation of the TBSA according to the rule of 9s:
Anterior Trunk: 18%
Right Arm: 9% (full arm on both posterior and anterior aspects)
Left Arm: 4.5% (only one half, from the elbow to the fingers in both anterior and posterior sides).
Then TBSA = 18 + 9 + 4.5
= 31.5%.
- Calculate the rate of infusion of lactated Ringer's, using the Parkland formula:
Parkland Formula:
Total fluid volume (mL) = 4 mL × client weight (kg) × % TBSA burned
Given:
- Client weight = 118.8 lb
- Burnt surface area = 31.5%
- Infusion starts at 2300 hours (11 PM)
- We need to find the rate at 0600 hours (6 AM)
Calculation:
- Convert client's weight from pounds (lb) to kilograms (kg):
Weight in kg = 118.8 lb / 2.2 lb/kg
= 54 kg
- Calculate the total fluid volume needed for the first 24 hours:
Total fluid volume (mL) = 4 mL × client weight (kg) × % TBSA burned
= 4 mL × 54 kg × 31.5%
= 4 × 54 × 31.5
= 6804 mL
- Determine the amount of fluid to be administered 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. The problem states the burn occurred, and the nurse starts the infusion at 2300. This implies 2300 is the "time of the burn"
Fluid for first 8 hours = 6804 mL / 2
= 3402 mL
- Calculate the time elapsed since the start of the infusion until 0600 hrs:
From 2300 (11 PM) to 0600 (6 AM) = 7 hours
This means 0600 is within the first 8 hours of resuscitation.
- Calculate the infusion rate for the first 8 hours.
Rate for first 8 hours (mL/hr) = Fluid for first 8 hours / 8 hours
= 3402 mL / 8 hours
= 425.25 mL/hr
- Round the answer to the nearest whole number.
= 425 mL/hr.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
C. Ease the visitor to the floor: This is the first priority to prevent injury. Safely guiding the person to the ground helps reduce the risk of trauma from falling.
A. Maintain a patent airway: Once on the ground, the nurse should position the person (ideally on their side) to promote airway patency and prevent aspiration.
D. Obtain vital signs: After the seizure ends, assessing vital signs helps evaluate postictal status and detect any complications such as hypoxia or hypotension.
B. Record the seizure activity observed: Documentation of the seizure’s onset, duration, and characteristics is important, but it comes after safety and assessment priorities are addressed.
Correct Answer is B
Explanation
A. Blood pressure 110/72 mm Hg: A blood pressure of 110/72 mm Hg is within the normal range and does not require intervention. Maintaining a stable blood pressure is essential after a craniotomy, and this reading indicates no immediate concerns.
B. Intracranial pressure (ICP) 25 mm Hg: An ICP of 25 mm Hg is above the normal range (typically 5-15 mm Hg). Elevated ICP can lead to brain herniation and other severe complications. The nurse should notify the healthcare provider immediately and take measures to reduce ICP, such as positioning and administering medications if needed.
C. PaCO2 35 mm Hg: A PaCO2 of 35 mm Hg is within the normal range (35-45 mm Hg). The normal level of carbon dioxide is important for maintaining appropriate cerebral perfusion pressure, and this value does not indicate a problem.
D. Pulse oximetry 96%: A pulse oximetry reading of 96% is within the normal range (95-100%) and indicates adequate oxygenation. No immediate intervention is needed unless the value drops significantly below this level.
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