# A 6-year-old child is admitted to the burn unit with second-degree burns covering 25% of the total body surface area (TBSA) from a house fire. The child is in the acute phase of burn injury. Which nursing intervention should be the priority during this phase? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542345 > language: ko > subject: Child Health ## 문제 A 6-year-old child is admitted to the burn unit with second-degree burns covering 25% of the total body surface area (TBSA) from a house fire. The child is in the acute phase of burn injury. Which nursing intervention should be the priority during this phase? ## 보기 1. Encourage high-protein, high-calorie oral intake to promote wound healing 2. Apply topical antibiotics to prevent infection at the burn sites 3. Provide pain medication only when the child requests it to avoid dependency 4. Monitor fluid and electrolyte balance closely and maintain adequate hydration **✔ 정답** **정답: 4** ## 해설 During the acute phase of burn injury, maintaining fluid and electrolyte balance is the highest priority to prevent hypovolemic shock and organ failure. Other interventions like nutrition, infection prevention, and pain management are important but secondary in this phase. ## 심화 해설 Understanding the Acute Phase of Burn Injury In the context of a 6-year-old child with 25% TBSA second-degree burns, the acute phase begins approximately 36 to 48 hours after the initial injury and lasts until the burn wounds are closed. This phase is marked by a profound shift in physiology. While the emergent phase is dominated by hypovolemic shock, the acute phase is characterized by a hypermetabolic and hyperdynamic state where the body attempts to heal. However, a persistent and critical threat throughout this phase is ongoing fluid and electrolyte imbalance, driven by massive fluid shifts from the intravascular space into the interstitial tissue and continuous insensible water loss. Why Fluid and Electrolyte Monitoring is the Priority The correct answer is to monitor fluid and electrolyte balance closely and maintain adequate hydration. This intervention takes priority because the physiological derangements of the acute phase directly threaten hemodynamic stability and organ function. The rationale is deeply rooted in the complex fluid dynamics following a major burn. A key, yet often underestimated, driver of fluid loss in this phase is transepidermal water loss (TEWL). When the skin's protective barrier is destroyed by a burn, water can evaporate freely from the wound surface. As highlighted by Arlati and Aseni, this evaporative loss is a "major but often neglected component of early fluid requirements" [1]. In a child with 25% TBSA burns, this continuous, invisible loss can be enormous, rapidly depleting intravascular volume and concentrating serum electrolytes. Failure to account for TEWL alongside ongoing insensible losses and metabolic demands can quickly lead to hypernatremia, hypovolemia, and prerenal kidney injury. Furthermore, the acute phase involves a complex inflammatory cascade. The initial systemic capillary leak, while most dramatic in the first 24 hours, can persist or recur. Fluid shifts from the bloodstream into the interstitial space, contributing to edema formation. The scoping review by Arlati and Aseni emphasizes the clinical challenge of achieving "accurate early fluid balance," a difficulty that extends well into the acute phase as clinicians must titrate fluid to support perfusion without exacerbating edema [1]. A bibliometric analysis comparing fluid resuscitation in burns and sepsis reinforces that the "optimal strategy of titrating fluids" remains a central and debated clinical question, underscoring the need for meticulous, individualized monitoring . For a pediatric patient, who has a smaller physiological reserve and a higher body water content, this monitoring is even more critical . Analysis of Incorrect Options - Option 1: Encourage high-protein, high-calorie oral intake. While initiating aggressive nutritional support is a cornerstone of care in the acute phase to combat the massive hypermetabolic response, it is not the immediate priority over hemodynamic stability. A child with a large burn may develop an ileus or have altered consciousness, making oral intake unsafe. Nutritional needs are typically met via enteral feeding tubes, and this intervention is secondary to ensuring the patient is adequately resuscitated and has stable renal and cardiovascular function. - Option 2: Apply topical antibiotics to prevent infection. Wound care and infection prevention are critical in the acute phase, as the burn wound is a primary source of sepsis. However, the application of topical agents is a local intervention. The systemic priority remains the "ABCs"—airway, breathing, and circulation. Fluid and electrolyte balance is a direct component of circulation and end-organ perfusion. A patient in fluid imbalance will not perfuse their wounds or vital organs effectively, rendering local wound care futile in the face of systemic shock. - Option 3: Provide pain medication only when the child requests it. This approach is fundamentally incorrect and unethical in modern burn care. Pain from a burn is severe and continuous, exacerbated by procedures like dressing changes. Administering analgesia only upon patient request ("PRN" without a scheduled baseline) leads to cycles of severe pain, anxiety, and undermines the patient's trust. Effective pain management in the acute phase requires a combination of scheduled, around-the-clock analgesics and additional pre-procedural doses, not a reactive, dependency-focused approach. A case report on pediatric burn care explicitly lists "analgesia" as an initial and ongoing measure, not a conditional one . Clinical Integration for the NCLEX-RN The NCLEX-RN tests the ability to prioritize care using frameworks like Maslow’s Hierarchy and the ABCs. In this scenario, fluid and electrolyte balance directly relates to physiological survival (the base of the pyramid) and the "C" (circulation) of the ABCs. The evidence from recent literature confirms that managing the complex fluid dynamics of the acute phase—from insensible evaporative loss to ongoing capillary leak—is a challenging and paramount task [1]. A nurse must vigilantly monitor intake and output, daily weights, serum electrolytes, and markers of perfusion (e.g., urine output, heart rate, level of consciousness) to guide fluid titration and prevent life-threatening complications such as hypovolemic shock, acute kidney injury, or pulmonary edema from over-resuscitation.References (research sources) - [1]From Evaporation to Edema: A Scoping Review of Physical and Biological Determinants of Early Fluid Distribution in Burn Patients.Research articleArlati S, Aseni P. (2026) · DOI: 10.3390/ebj7020021 ## 임상 시나리오 Pediatric Burn Acute Phase: Fluid PriorityHemodynamic stability overrides all other interventions During the acute phase, massive fluid shifts and transepidermal water loss (TEWL) from denuded skin create a continuous demand for fluid. Strict monitoring of urine output (1-2 mL/kg/hr in children), daily weight, and electrolytes is the priority to prevent hypovolemic shock and acute kidney injury. Colloid resuscitation may be initiated after the first 24 hours to restore intravascular volume and reduce edema. Enteral nutrition should be started early via a feeding tube, as paralytic ileus often prevents adequate oral intake. CautionDo not rely on thirst or oral intake for hydration. Fluid creep (excessive resuscitation) is a risk; titrate fluids strictly to objective physiological endpoints, not formula alone. ## 핵심 개념 - **Transepidermal Water Loss (TEWL)** — Continuous, invisible evaporative loss from denuded skin that significantly increases fluid requirements in the acute phase. - **Acute Phase of Burn Injury** — Begins ~36-48 hours post-burn, marked by hypermetabolism, massive fluid shifts, and diuresis, lasting until wound closure. - **Capillary Leak Syndrome** — Systemic increase in capillary permeability causing ongoing loss of intravascular fluid, protein, and electrolytes into the interstitium. ## 같은 주제 문제 - [A 4-year-old child is brought to the emergency department with burns covering 18% of the t…](https://mymerci.kr/pages/nclex_q.php?qn_id=542342) - [A 4-year-old child is brought to the emergency department with burns covering 18% of the t…](https://mymerci.kr/pages/nclex_q.php?qn_id=542343) - [A 2-year-old toddler is brought to the emergency department with burns covering 20% of the…](https://mymerci.kr/pages/nclex_q.php?qn_id=542344) - [A 10-year-old child with 35% total body surface area (TBSA) burns is admitted to the pedia…](https://mymerci.kr/pages/nclex_q.php?qn_id=542346) - [A 6-year-old child sustained second-degree burns covering 15% of the body surface area fro…](https://mymerci.kr/pages/nclex_q.php?qn_id=542347) - [A 4-year-old child is brought to the emergency department with second-degree burns coverin…](https://mymerci.kr/pages/nclex_q.php?qn_id=542348) - [A 4-year-old child is admitted to the pediatric burn unit with second-degree burns coverin…](https://mymerci.kr/pages/nclex_q.php?qn_id=542349) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._