A client has 30 percent burn over her legs. When she comes to emergency unit, your priority action is to:

IGNOU PB Bsc Entrance-2023

Medical & Surgical Nursing

Hard

Appeared in: IGNOU PB Bsc Entrance-2023

Explanation

In emergency care, the priority is always Airway, Breathing, and Circulation (ABC).
With burns localized to the legs, the airway and breathing are presumed to be intact, making circulation the immediate priority.
A 30% TBSA burn causes a massive fluid shift from the intravascular to the interstitial space, leading to a high risk of hypovolemic (burn) shock.
Starting an IV line is the essential first step for fluid resuscitation to combat shock, maintain blood pressure, and ensure vital organ perfusion.
According to burn management guidelines, patients with burns greater than 15% TBSA require formal intravenous fluid resuscitation.

Option A: Wound cleaning is important to prevent infection but is not the immediate life-saving priority. It is performed after the patient is hemodynamically stable.
Option B: Endotracheal intubation is the priority for airway management. Since the burns are on the legs, there is no indication of an inhalation injury or airway compromise (e.g., facial burns, soot in sputum, stridor).
Option C: A full head-to-toe assessment is part of the secondary survey in trauma care. It is performed only after life-threatening conditions identified in the primary survey (like circulatory collapse) have been addressed.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Priority nursing interventions in the emergent phase of major burn management as background academic context rather than a clinical decision trigger.
For major burns, it is standard practice to establish at least two large-bore IV lines to accommodate the rapid infusion of large fluid volumes.
The Parkland formula (4 mL of Lactated Ringer's solution per kg of body weight per %TBSA burned) is commonly used to calculate fluid requirements for the first 24 hours.
Monitoring hourly urine output (aiming for 0.5-1 mL/kg/hr in adults) is the most reliable non-invasive indicator of adequate fluid resuscitation and renal perfusion.

How to Approach the Question

First, identify the question type. This is a clinical scenario asking for the priority nursing action.
Recall the standard framework for prioritization in emergencies: Airway, Breathing, Circulation (ABC).
Analyze the patient's condition: a 30% burn is a major injury.
Assess the location of the injury: burns are on the legs. This information helps determine which part of the ABC framework is most at risk.
Evaluate the options based on the ABCs: Since the airway is not compromised by leg burns, the immediate life threat is circulatory collapse from fluid loss.
Select the option that addresses the most immediate life-threatening problem. Starting an IV line directly addresses 'Circulation' by preparing for fluid resuscitation to prevent shock.

Concept Tested & Keywords

Concept Tested: Priority nursing interventions in the emergent phase of major burn management.
Stem keywords: 30 percent burn, legs, emergency unit, priority action
Lead-in keywords: priority action
Clinical cues: A 30% burn is classified as a major burn, indicating a systemic response and high risk of shock.
Clinical cues: The burn location on the legs makes an inhalation injury less likely, shifting the priority from airway to circulation.

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E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 691-693