# A nurse is caring for a 70-kg adult client admitted to the burn ICU 2 hours after a kitchen flash fire. Burn assessment using the Rule of Nines: full-thickness burns to anterior chest and abdomen (18%), partial-thickness burns to the entire right arm (9%), and partial-thickness to the anterior right leg (9%). Total burn surface area (TBSA) is 36%. Vital signs: BP 96/64, HR 124, RR 24, urine output 18 mL/hr. Which initial actions are required? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=368300&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A nurse is caring for a 70-kg adult client admitted to the burn ICU 2 hours after a kitchen flash fire. Burn assessment using the Rule of Nines: full-thickness burns to anterior chest and abdomen (18%), partial-thickness burns to the entire right arm (9%), and partial-thickness to the anterior right leg (9%). Total burn surface area (TBSA) is 36%. Vital signs: BP 96/64, HR 124, RR 24, urine output 18 mL/hr. Which initial actions are required? Select all that apply. 1 Insert an indwelling catheter, monitor urine output hourly, and titrate fluid to 30–50 mL/hr. 2 Insert two large-bore peripheral IVs through unburned skin when possible. 3 Assess for inhalation injury and prepare for early intubation if airway compromise is suspected. 4 Apply ice or cold packs directly to the burned areas to limit tissue injury. 5 Begin lactated Ringer at 2 mL/kg/%TBSA (5,040 mL/24 hr), with half due in the first 8 hours after injury. 6 Cover all burned areas with sterile saline-soaked gauze for the first 24 hours. ## Explanation This client has a major burn with shock findings. Option 1 is correct because hourly urine output is used to titrate resuscitation toward an adult target of about 30-50 mL/hr. Option 2 is correct because two large-bore peripheral IVs permit rapid crystalloid administration. Option 3 is correct because a flash fire requires prompt assessment for inhalation injury and early airway control if compromise is suspected. Option 4 is incorrect because direct ice causes vasoconstriction and can deepen tissue injury. Option 5 is correct: current ABA guidance starts adult burn-shock resuscitation at 2 mL/kg/percent TBSA, or 5,040 mL for this client, with half allocated to the first 8 hours from injury and subsequent titration to clinical response. Option 6 is incorrect because large wet dressings increase heat loss and hypothermia risk. ## In-depth explanation Major-burn priorities Use ABCs first: assess for inhalation injury, secure large-bore IV access, begin warmed lactated Ringer, insert a urinary catheter, and follow hourly urine output and perfusion. Current starting estimate The 2024 American Burn Association guideline recommends initiating adult burn-shock resuscitation at 2 mL/kg/%TBSA. Here, 2 × 70 × 36 = 5,040 mL over 24 hours, with half allocated to the first 8 hours from injury. This is a starting estimate, not a fixed dose; titrate to response and avoid fluid creep. Avoid Direct ice worsens local ischemia, and extensive wet dressings promote hypothermia. Source American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation — https://academic.oup.com/jbcr/article/45/3/565/7458089 ## Clinical scenario Scenario 70 kg adult, 2 hours after a kitchen flash fire. TBSA - Anterior chest and abdomen: 18 percent - Entire right arm: 9 percent - Anterior right leg: 9 percent - Total TBSA: 36 percent Status - BP 96/64, HR 124, RR 24 - Urine output 18 mL/hr Starting estimate Current ABA adult burn-shock guidance: 2 mL x 70 kg x 36 percent = 5,040 mL lactated Ringer over 24 hours; half is allocated to the first 8 hours after injury and the rate is titrated to response. ## Key concepts - **Parkland formula** — Standard burn fluid resuscitation formula for adults: 4 mL by kg body weight by percent TBSA equals total volume of lactated Ringer over the first 24 hours from time of injury. Half is given in the first 8 hours, half in the next 16 hours. Titrated to urine output 30 to 50 mL/hr in adults, 1 mL/kg/hr in children. Modified Brooke (2 mL/kg/percent TBSA) is used in some centers. Time clock starts at INJURY, not arrival. - **Rule of Nines** — Adult burn TBSA estimation: head 9 percent, each arm 9 percent, anterior trunk 18 percent, posterior trunk 18 percent, each leg 18 percent, perineum 1 percent. Children differ: head 18 percent in infants with smaller torso percentages. For irregular patterns: palmar method (palm and fingers approximately 1 percent TBSA) or Lund-Browder chart (most accurate, age-adjusted). - **Inhalation injury** — Suspect with face or neck burns, closed-space fire, singed nasal hair or eyebrows, carbonaceous sputum, hoarseness, stridor, wheezing, or dyspnea. Mechanisms: thermal injury to upper airway, chemical injury to lower airway from smoke, carbon monoxide and cyanide poisoning. 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