An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Which of the following fluid would be started by on duty nurses?

1. A

   Ringer lactate

2. B

   Normal saline 0.9%

3. C

   DNS

4. D

   Normal saline 0.45% with dextrose 10%

Appeared in: NORCET -4 , 2023

Explanation

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• Ringer's Lactate is the preferred isotonic crystalloid for initial fluid resuscitation in major burn patients.
• Its composition closely resembles the body's extracellular fluid, making it effective for restoring intravascular volume.
• The lactate in the solution is metabolized by the liver into bicarbonate, which helps to correct the metabolic acidosis often seen in burn shock.
• Major burn resuscitation protocols, like the Parkland formula, specifically recommend Ringer's Lactate for the first 24 hours.

Why Other Options Were Wrong

• Option B: While also an isotonic crystalloid, large-volume resuscitation with 0.9% Normal Saline can lead to hyperchloremic metabolic acidosis due to its high chloride content.
• Option C: The dextrose in DNS can worsen the stress-induced hyperglycemia common in burn patients and cause osmotic diuresis, which further depletes fluid volume.
• Option D: This is a hypertonic solution and is inappropriate for initial volume expansion in burn shock. It can worsen cellular dehydration and cause dangerous fluid shifts.

Related Visual

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Fluid resuscitation in major burn injuries as background academic context rather than a clinical decision trigger.
• Accurate and rapid fluid resuscitation is a critical nursing intervention to prevent burn shock, organ failure, and death in patients with major burns.
• Nurses are responsible for calculating fluid requirements (often using the Parkland formula), initiating and titrating IV fluids, and meticulously monitoring the patient's response, especially urine output, which is the primary indicator of adequate resuscitation.
• What if? If the patient had a history of severe liver failure, the use of Ringer's Lactate might be reconsidered, as the liver is responsible for metabolizing lactate to bicarbonate. In such a case, an alternative crystalloid like Plasma-Lyte or even normal saline might be chosen, with careful monitoring for acidosis.

How to Approach the Question

• First, identify the core clinical problem: a patient with major burns. Using the 'Rule of Nines,' two entire legs (2 x 18% = 36%) plus the perineum (1%) equals a Total Body Surface Area (TBSA) of approximately 37%, which constitutes a major burn.
• Recall the primary goal in the emergent phase of burn care: preventing hypovolemic (burn) shock through aggressive fluid resuscitation.
• Access your knowledge about the standard-of-care fluid for this specific, high-stakes condition.
• Evaluate the options based on their composition and physiological effects. Ringer's Lactate is isotonic and contains lactate to buffer acidosis. Normal saline is also isotonic but can cause acidosis in large volumes. Dextrose-containing solutions are generally avoided initially due to hyperglycemia risk.
• Select the option that is most physiologically appropriate and recommended by established protocols (e.g., Parkland formula) for initial burn resuscitation.

Concept Tested & Keywords

• Concept Tested: Fluid resuscitation in major burn injuries
• Stem keywords: adult client, emergency department, burns, entire legs, perineal area, fluid
• Lead-in keywords: which of the following
• Clinical cues: Burns to both entire legs and the perineal area indicates a major burn requiring significant fluid resuscitation.
• Negative lead-in flag: false

Question ID

QTWtGnAXCeq1j8-CqWge3z

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 142-144

E6 Gynecology Williams p. 50-74

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 571-573