Care Manager Certification Practice Exam

In caring for a client with a 30% burn injury to the lower extremities, what intervention should the nurse perform first?

1. Clean and dress the wound.

2. Administer pain medication.

3. Administer a tetanus booster.

4. Administer IV fluids.

The correct answer is: Administer IV fluids.

In the scenario of a client with a 30% burn injury, administering IV fluids is a critical first intervention. This is due to the significant fluid loss that can occur with extensive burns, which can lead to hypovolemic shock if not managed promptly. The priority is to stabilize the patient and maintain adequate circulation and organ perfusion. When burns cover a large surface area, as with a 30% burn, the body's response involves rapid fluid shifts away from the vascular system and into the burned tissue. This increases the risk of dehydration and can severely compromise the patient's hemodynamic stability. Initiating fluid resuscitation early not only helps to maintain blood pressure but also prevents complications associated with inadequate fluid volume, such as renal failure or cardiac issues. While managing pain, cleaning and dressing the wound, and addressing immunization status are important components of comprehensive burn care, they are secondary to the immediate need for fluid resuscitation. Focusing on fluid administration first aligns with the standard burn management protocols, highlighting the importance of restoring circulatory volume as a priority.