ESTUDYR
NCLEX-RN Case Study: Major Burn Injury
Client Scenario
0900 Emergency Department:
A 35-year-old male is brought in by EMS after a house fire. He was found in a smoke-filled
room. He is awake and screaming in pain.
Physical Assessment:
Respiratory: Soot is noted around the nose and mouth. Singed nasal hairs present.
He has a hoarse voice and a frequent "brassy" cough.
Integumentary: Deep partial-thickness and full-thickness burns are noted on the
entire front of the torso (chest and abdomen) and the entire left arm.
Vital Signs: BP 100/60, HR 122, RR 26, SpO2 94% on 100% humidified oxygen.
Item 1: Recognizing Cues (Visual/Calculation)
Question: Using the Rule of Nines diagram below, calculate the total body surface area
(TBSA) percentage of the client's burns.
Calculation:
Front Torso (Chest + Abdomen): 18%
Entire Left Arm: 9%
Total TBSA: ✅27%
Rationale: Accurate calculation of TBSA is the first step in determining fluid resuscitation
needs. The front torso is 18% (9% chest, 9% abdomen) and one full arm is 9%.
Item 2: Analyzing Cues (Prioritization)
Question: Which finding is the nurse's highest priority for immediate intervention?
1. Pain level expressed as 10/10.
2. ✅Hoarse voice and singed nasal hairs.
NCLEX-RN Case Study: Major Burn Injury
Client Scenario
0900 Emergency Department:
A 35-year-old male is brought in by EMS after a house fire. He was found in a smoke-filled
room. He is awake and screaming in pain.
Physical Assessment:
Respiratory: Soot is noted around the nose and mouth. Singed nasal hairs present.
He has a hoarse voice and a frequent "brassy" cough.
Integumentary: Deep partial-thickness and full-thickness burns are noted on the
entire front of the torso (chest and abdomen) and the entire left arm.
Vital Signs: BP 100/60, HR 122, RR 26, SpO2 94% on 100% humidified oxygen.
Item 1: Recognizing Cues (Visual/Calculation)
Question: Using the Rule of Nines diagram below, calculate the total body surface area
(TBSA) percentage of the client's burns.
Calculation:
Front Torso (Chest + Abdomen): 18%
Entire Left Arm: 9%
Total TBSA: ✅27%
Rationale: Accurate calculation of TBSA is the first step in determining fluid resuscitation
needs. The front torso is 18% (9% chest, 9% abdomen) and one full arm is 9%.
Item 2: Analyzing Cues (Prioritization)
Question: Which finding is the nurse's highest priority for immediate intervention?
1. Pain level expressed as 10/10.
2. ✅Hoarse voice and singed nasal hairs.
