Maryland Next Gen NCLEX Test Bank Project

September 1, 2022; Updated May 16, 2023

Case Study Topic: Burns (2nd & 3rd degree) Author: Stacy McGrath, Ed.D, MSN, RN,
(with Trend) Salisbury University

Case Summary

A 55-year-old female is admitted to the burn unit at 2000 after sustaining second and third degree
burns to 36% of Total Body Surface Area in a house fire. The fire occurred at 1800 today. The client
was brought to the Emergency Room by ambulance. She was stabilized and fluids were started and
then she was transferred to the burn unit. The client shows signs of shock, and the nurse plans care
and evaluates outcomes.

Objectives

1. Recognize cues in a client with burns.

2. Identify the signs and symptoms of client with burn shock.
3. Plan care for a client with burn shock.
4. Identify pathological changes that occur with burns.
5. Evaluate client’s outcomes following nursing intervention.

Case Study Link Case Study QR Code

https://umaryland.az1.qualtrics.com/jfe/
form/SV_cC45X6a615zWvnE

Trend QR Code Trend Link

https://umaryland.az1.qualtrics.com/jfe/
form/SV_2atRY9jdqxbMzaK

Case References

1. Ignatavicius, D., Workman, M. L. & Rebar, C. R. (2018). Medical-surgical nursing: Concepts for
interprofessional collaborative care (9th ed.)
Case Study Question 1 of 6

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
Vital Signs
Time 2000 2100
Temperature 37.8 C/100 F 37.5 C/99.5 F
Heart rate 130 135
Respirations 28 32
Blood pressure 88/58 80/54
Pulse oximeter 92 on 4L NC 92 on 4L NC
Pain 6/10 4/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned = 14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100
IV rate 1200 mL/hr 1200 mL/hr
IV intake Started 600 mL RL
Output 20 mL

 Drag the 4 findings are urgent to follow-up to the box on the right.

Client Findings Top 4 Findings

Respirations *
Pitting edema
Blood pressure *
Urine output *
Heart rate *
Temperature
Pulse oximeter
Pain

Scoring Rule: 0/1

Rationale: The nurse will need to follow up on findings that indicate the client may be having
respiratory distress or shock; increased respirations, drop in blood pressure, tachycardia, and decreased
urinary output. The pulse oximeter is low, but not critical. A client with burns will have pitting edema as
a result of fluid shifting but it would not be a priority finding over any airway issues. Clients with burns
will have thermoregulation and pain issues but again, the airway and blood pressure need to be
addressed quickly.
Case Study Question 2 of 6

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55 -year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
Vital Signs
Time 2000 2100
Temperature 37.8 C/100 F 37.5 C/99.5 F
Heart rate 130 135
Respirations 28 32
Blood pressure 88/58 80/54
Pulse oximeter 92 on 4L NC 92 on 4L NC
Pain 6/10 4/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned = 14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100
IV rate 1200 ml/hr 1200 mLl/hr
IV intake Started 600 ml RL
Output 20 ml

 For each client finding click to specify whether the finding is consistent with compartment
syndrome, inhalation injury, or distributive shock. Each assessment may support more than one
condition.

Finding Compartment Inhalation Distributive

syndrome injury Shock
Urine output □ □ □ *
Tachypnea □ □ * □ *
Blood pressure □ □ □ *
Peripheral edema □ * □ □ *
Pain □ * □ □
Note: Each column must have at least one finding.

Scoring Rule: +/-

Rationale: If the client is progressing into shock from their injuries, they will have low blood pressure,
and an elevated heart rate and respirations. They may also experience edema as fluid shifts which can
lead to peripheral edema. Since the fluid is shifting, they become hypovolemic and the urinary output
declines. Clients with compartment syndrome have pain and peripheral edema. Clients with burns can
experience airway obstruction and tachypnea at any point after the event due to smoke or inhalation
injuries. This manifests as tachypnea, dyspnea, or changes in breaths sounds.
Case Study Question 3 of 6

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
Vital Signs
Time 2000 2030
Temperature 37.8 C/100 F 37.5 C/99.5 F
Heart rate 130 135
Respirations 28 32
Blood pressure 88/58 80/54
Pulse oximeter 92 on 4L NC 92 on 4L NC
Pain 6/10 4/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned = 14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100
IV rate 1200 ml/hr 1200 mL/hr
IV intake Started 600 ml RL
Output 20 ml

 Complete the sentence from the list of drop-down options.

The client is at most risk for complications associated with compartment syndrome
inhalation injury
distributive shock*
The client care priority is to assist with intubation
increase fluids*
relieve compression

Scoring Rule: 0/1

Rationale: Clients with major burns can go into shock due to massive fluid shifting. Signs of distributive
shock will include increased heart rate and respirations and decreased blood pressure. While the
respiratory rate is increasing, the pulse oximeter is not decreasing on low levels of oxygen. Edema is
seen with compartment syndrome, but pain is typically severe and there would be other neurovascular
findings.
Case Study Question 4 of 6

The nurse cares for a 55- year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
Vital Signs
Time 2000 2030
Temperature 37.8 C/100 F 37.5 C/99.5 F
Heart rate 130 135
Respirations 28 32
Blood pressure 88/58 80/54
Pulse oximeter 92 on 4L NC 92 on 4L NC
Pain 6/10 4/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned =14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100
IV rate 1200 mL/hr 1200 ml/hr
IV intake Started 600 ml RL
Output 20 mL

 The nurse contacts the physician about the client’s status. What orders does the nurse anticipate
including in the plan of care?

Potential order Indicated Not indicated

Obtain a blood gas o X o
Double the infusion IV rate o o X
Monitor basic metabolic panel o X o
Obtain a chest X-ray o X o
Culture wounds o o X

Scoring Rule: 0/1

Rationale: While aggressive fluid resuscitation is needed, it must be done judiciously to prevent fluid
overload and pulmonary complications. A chest-Xray and blood gas should be obtained to assess
pulmonary status. IV rates are typically increased no more than 20% per hour to prevent fluid overload.
Monitoring metabolic panel helps assess fluid and electrolyte imbalances. It is too soon to suspect a
wound infection.

Case Study Question 5 of 6

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55-year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
Vital Signs
Time 2000 2100
Temperature 37.8 C/100 F 37.5 C/99.5 F
Heart rate 130 135
Respirations 28 32
Blood pressure 88/58 80/54
Pulse oximeter 92 on 4L NC 92 on 4L NC
Pain 6/10 4/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned = 14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100
IV rate 1200 ml/hr 1200 ml/hr
IV intake Started 600 ml RL
Output 20 ml
Orders
 Obtain chest Xray, ABG, Complete metabolic panel
 Oxygen per nasal cannula 2 to 6 Liters to maintain pulse oximetry at 92 or greater
 Titrate IVF based on urine output up to a maximum of 2000 ml/hr:
o <15ml/hr - increase IV rate 20%
o 15-29 ml/hr - ncrease IVF 10%
o 30-50 ml/hr - leave current rate
o >50ml/hr - decrease 10%
 Give 500 mL 5% albumin over 2 hours as needed for systolic B/P<80, diastolic B/P<50

The physician assesses the client and the nurse receives orders.

 What action should the nurse take first?

o Obtain a chest Xray
o Obtain an ABG
o Increase the IV rate*
o Give albumin
Scoring Rule: 0/1

Rationale: The most critical intervention is to increase the IVF. The chest Xray and blood gas can be
done after the fluids are increased. The vital signs do not yet indicate albumin is needed.
Case Study Question 6 of 6

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
2200: IV rate increased. Labs drawn. Portable chest done.
2300: Audible stridor
Vital Signs
Time 2000 2100 2200 2300
Temperature 37.8 C/100 F 37.5 C/99.5 F 37.6 C/99.7 F 37.6 C/99.7 F
Heart rate 130 135 138 136
Respirations 28 32 35 38
Blood pressure 88/58 80/54 82/56 84/54
Pulse oximeter 92 on 4L NC 92 on 4L NC 91 4L NC 90 6 L NC
Pain 6/10 4/10 5/10 5/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight X body surface burned = 14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100 2200 2300
IV rate 1200 ml/hr 1200 ml/hr 1320 ml//hr 1320 ml/hr
IV intake Started 600 ml RL 1200 RL 1320 RL
Output 20 ml 10 ml 50 ml
Orders
 Obtain chest Xray, ABG, complete metabolic panel
 Oxygen per nasal cannula 2 to 6 Liters to maintain pulse oximetry at 92 or greater
 Titrate IVF based on urine output up to a maximum of 2000mL/hr:
o <15 ml/hr - increase IV rate 20%
o 15-29 ml/hr - increase IVF 10%
o 30-50 ml/hr - leave current rate
o >50 ml/hr - decrease 10%
 Give 500 ml 5% albumin over 2 hours as needed for systolic B/P<80, diastolic B/P<50
Diagnostic Report
 Chest X-ray shows minimal inhalation injury
The nurse reassesses the client at 2300.

 For each finding, click to indicate if the finding indicates the client’s condition has improved,
declined, or is unchanged.

Finding Improved Declined Unchanged

Blood pressure o o o *
Heart rate o o o *
Urine output o * o o
Oxygen saturation o o * o
Breath sounds o o * o
Temperature o o o *

Scoring Rule: 0/1

Rationale: The client’s hemodynamic status is stabilizing with fairly consistent heart and blood pressure
measurements. The temperature also has remained fairly stable. Urine output of 50 mL an hour is a sign
of improved renal perfusion. Stridor and decreased pulse oximeter readings suggest the development of
upper airway edema.
Trend

The nurse cares for a 55- year-old female admitted to the burn unit following a house fire.

Nurses’ Notes
2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral
second and third degree burns to the front lower extremities from a house fire that occurred at 1800
today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs/100 kg. Fluid
resuscitation started with Ringer’s lactate IV.
2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Wound care
was provided by the nurse. Breath sounds clear. Bilateral +2 pitting edema was noted in the lower
extremities. Doppler pedal pulses present.
2200: IV rate increased. Labs drawn. Portable chest done.
2300: Audible stridor
Vital signs
Time 2000 2100 2200 2300
Temperature 37.8 C/100 F 37.5 C/99.5 F 37.6 C/99.7 F 37.6 C/99.7 F
Heart rate 130 135 138 136
Respirations 28 32 35 38
Blood pressure 88/58 80/54 82/56 84/54
Pulse oximeter 92 on 4L NC 92 on 4L NC 91 4L NC 90 6 L NC
Pain 6/10 4/10 5/10 5/10
Intake & Output
Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned =14,400 mL
Give half 8 hours since burn event and the second half over remaining 24 hours
Hour 2000 2100 2200 2300
IV rate 1200 ml/hr 1200 ml/hr 1320 ml/hr 1320 ml/hr
IV intake Started 600 mL RL 1200 RL 1320 RL
Output 20 ml 10 ml 50 ml
Orders
 Obtain chest Xray, ABG, Complete metabolic panel
 Oxygen per nasal cannula 2 to 6 Liters to maintain pulse oximetry at 92 or greater
 Titrate IVF based on urine output up to a maximum of 2000mL/hr:
o <15 ml/hr - increase IV rate 20%
o 15-29 ml/hr - increase IVF 10%
o 30-50 ml/hr - leave current rate
o >50 mL/hr - decrease 10%
 Give 500 mL 5% albumin over 2 hours as needed for systolic B/P<80, diastolic B/P<50
Diagnostic Report
 Chest X-ray shows minimal inhalation injury

The nurse reassesses the client at 2300 after implementing the treatment plan.

 For each finding, click to indicate if the finding indicates the client’s condition has improved,
declined, or is unchanged.
 Finding Improved Declined Unchanged
Blood pressure o o o *
Heart rate o o o *
Urine output o * o o
Oxygen saturation o o * o
Breath sounds o o * o
Temperature o o o *

Scoring Rule: 0/1

Rationale: The client’s hemodynamic status is stabilizing with fairly consistent heart and blood pressure
measurements. The temperature also as remained fairly stable. Urine output of 50 mL an hour is a sign
of improved renal perfusion. Stridor and decreased pulse oximeter readings suggest the development of
upper airway edema.