TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING
11TH EDITION BY HARDING Questions & Answers
satisfaction guaranteed success(CHAPTERS21-29)latest
update
Chapter 21: Burns
Test Bank MUL
TIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the n
A A A
urse notes that the skin is dry, pale, hard skin. The patient states that the bu
A A A
rn is not painful. What term would the nurse use to document theburn dept
h?
a. First-degree skin destruction
b. Full-thickness skin destruction
A A
c. Deep partial-thickness skin destruction
d. Superficial partial-
thickness skin destruction ANS: B
A
With full-
thickness skin destruction, the appearance is pale and dry or leathery and the
A
area is painless becauseof the associated nerve destruction. Erythema, swelli
ng, and blisters point to a deep partial-thickness burn.
With superficial partial-
,thickness burns, the area is red, but no blisters are present. First-
degree burns exhibiterythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity A
2. On admission to the burn unit, a patient with an approximate 25% total b
A
ody surface area (TBSA) burn hasthe following initial laboratory results: H
A A
ct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and
A A
serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate t
A
aking now?
a. Monitor urine output every 4 hours.
A A
b. Continue to monitor the laboratory results.
A A
c. Increase the rate of the ordered IV solution.
A A A A A A A
d. Type and crossmatch for a blood transfusion.
A
ANS: C
,The patients laboratory data show hemoconcentration, which may lead to a
decrease in blood flow to the microcirculation unless fluid intake is increase
d. Because the hematocrit and hemoglobin are elevated, a transfusion is inap
propriate, although transfusions may be needed after the emergent phase onc
e the patients fluid balance has been restored. On admission to a burn unit, th
A
e urine output would be monitored more oftenthan every 4 hours; likely ever
A A A
y1 hour.
DIF: Cognitive Level: Apply (application)
, TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. A patient is admitted to the burn unit with burns to the head, face, and ha
nds. Initially, wheezes are heard,but an hour later, the lung sounds are dec
A A A
reased and no wheezes are audible. What is the best action for the nurse to
A A A
take?
a. Encourage the patient to cough and auscultate the lungs again. A
b. Notify the health care provider and prepare for endotracheal intubatio
A A A A A A A A A
n.
c. Document the results and continue to monitor the patients respiratory
A A
rate.
d. Reposition the patient in high-
A A
Fowlers position and reassess breath sounds.
A
ANS: B
The patients history and clinical manifestations suggest airway edema and the
11TH EDITION BY HARDING Questions & Answers
satisfaction guaranteed success(CHAPTERS21-29)latest
update
Chapter 21: Burns
Test Bank MUL
TIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the n
A A A
urse notes that the skin is dry, pale, hard skin. The patient states that the bu
A A A
rn is not painful. What term would the nurse use to document theburn dept
h?
a. First-degree skin destruction
b. Full-thickness skin destruction
A A
c. Deep partial-thickness skin destruction
d. Superficial partial-
thickness skin destruction ANS: B
A
With full-
thickness skin destruction, the appearance is pale and dry or leathery and the
A
area is painless becauseof the associated nerve destruction. Erythema, swelli
ng, and blisters point to a deep partial-thickness burn.
With superficial partial-
,thickness burns, the area is red, but no blisters are present. First-
degree burns exhibiterythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity A
2. On admission to the burn unit, a patient with an approximate 25% total b
A
ody surface area (TBSA) burn hasthe following initial laboratory results: H
A A
ct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and
A A
serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate t
A
aking now?
a. Monitor urine output every 4 hours.
A A
b. Continue to monitor the laboratory results.
A A
c. Increase the rate of the ordered IV solution.
A A A A A A A
d. Type and crossmatch for a blood transfusion.
A
ANS: C
,The patients laboratory data show hemoconcentration, which may lead to a
decrease in blood flow to the microcirculation unless fluid intake is increase
d. Because the hematocrit and hemoglobin are elevated, a transfusion is inap
propriate, although transfusions may be needed after the emergent phase onc
e the patients fluid balance has been restored. On admission to a burn unit, th
A
e urine output would be monitored more oftenthan every 4 hours; likely ever
A A A
y1 hour.
DIF: Cognitive Level: Apply (application)
, TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. A patient is admitted to the burn unit with burns to the head, face, and ha
nds. Initially, wheezes are heard,but an hour later, the lung sounds are dec
A A A
reased and no wheezes are audible. What is the best action for the nurse to
A A A
take?
a. Encourage the patient to cough and auscultate the lungs again. A
b. Notify the health care provider and prepare for endotracheal intubatio
A A A A A A A A A
n.
c. Document the results and continue to monitor the patients respiratory
A A
rate.
d. Reposition the patient in high-
A A
Fowlers position and reassess breath sounds.
A
ANS: B
The patients history and clinical manifestations suggest airway edema and the
