C HAPTER 25: B URNS
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. Contracture development leading to impaired phy sical mobility can
occur after a major burn injury. Splints are applied to prevent or correct
contractures. Priority nursing interventions concerning this therapy
include which action?
a. Dail y assessment for proper fit and effectiveness
b. Removal of splints d uring showers and dressing changes
c. Allowing for frequent breaks from splint use
d. Passive and active range of motion may be used instead of splints
ANS: A
Splints can be used to prevent or correct contracture or to immobilize
joints after grafting. If spli nts are used, they must be checked dail y for
proper fit and effectiveness. Splints that are used to immobilize body
parts after grafting must be left on at all times, except to assess the
graft site for pressure points during every shift. Splints to correc t
severe contracture may be off for 2 hours per shift to allow burn care
and range-of-motion exercises.
PTS: 1 DIF: Cognitive Level: Anal yzing OBJ: Nursing
Process Step: Implementation TOP: Burns
MSC: NC LEX: Physiological Integrit y: Physiologica l
Adaptation
,2. Which topical antimicrobial agent is commonl y used as a broad -
spectrum agent and is activated by the wound moisture?
a. Silver
b. Bacitracin
c. Mafenide acetate cream
d. Silver sulfadiazine
ANS: A
Silver has long been used for the treatment of wounds because of its
broad-spectrum bacteriostatic properties against gram -negative and
gram-positive bacteria. Silver has minimal side effects and minimal
bacterial resistance. The other agents are applied topicall y and are not
activated by wound moisture.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Implementation TOP: Burns
MSC: NC LEX: Physiological Integrit y: Pharmacological
Therapies
3. A patient is admitted after being burned in a car fire. The wound surface
is red with patchy w hite areas that blanch with pressure but no blister
formation. What kind of burn would the nurse document in the patient’s
record?
a. Superficial partial -thickness burn
b. Moderate partial -thickness burn
c. Deep dermal partial -thickness burn
d. Full-thickness burn
, ANS: C
Deep-dermal partial-thickness (second -degree) burns involve the entire
epidermal layer and deeper layers of the dermis. A deep-dermal partial -
thickness burn usually is not characterized by blister formation. Onl y a
modest plasma surface leakage occu rs because of severe impairment in
blood suppl y. The wound surface usuall y is red with patchy white areas
that blanch with pressure.
PTS: 1 DIF: Cognitive Level: Understanding OBJ:
Nursing Process Step: Assessment TOP: Burns MSC:
NCLEX: Physiological Integrit y: Physiological Adaptation
4. A patient is brought to the emergency department after a house fire. He
fell asleep with a lit cigarette, and the couch ignited. What is the nurse’s
first priorit y?
a. Clean the wounds and remove blisters.
b. Assess the airway and provide 100% ox ygen.
c. Place a urinary drainage catheter and assess for m yoglobin.
d. Place a central intravenous access and provide antibiotics.
ANS: B
The first priorit y of emergency burn care is to secure and protect the
airway. All patients wi th major burns or suspected inhalation injury are
initiall y administered 100% ox ygen.
PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing
Process Step: Implementation TOP: Burns
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. Contracture development leading to impaired phy sical mobility can
occur after a major burn injury. Splints are applied to prevent or correct
contractures. Priority nursing interventions concerning this therapy
include which action?
a. Dail y assessment for proper fit and effectiveness
b. Removal of splints d uring showers and dressing changes
c. Allowing for frequent breaks from splint use
d. Passive and active range of motion may be used instead of splints
ANS: A
Splints can be used to prevent or correct contracture or to immobilize
joints after grafting. If spli nts are used, they must be checked dail y for
proper fit and effectiveness. Splints that are used to immobilize body
parts after grafting must be left on at all times, except to assess the
graft site for pressure points during every shift. Splints to correc t
severe contracture may be off for 2 hours per shift to allow burn care
and range-of-motion exercises.
PTS: 1 DIF: Cognitive Level: Anal yzing OBJ: Nursing
Process Step: Implementation TOP: Burns
MSC: NC LEX: Physiological Integrit y: Physiologica l
Adaptation
,2. Which topical antimicrobial agent is commonl y used as a broad -
spectrum agent and is activated by the wound moisture?
a. Silver
b. Bacitracin
c. Mafenide acetate cream
d. Silver sulfadiazine
ANS: A
Silver has long been used for the treatment of wounds because of its
broad-spectrum bacteriostatic properties against gram -negative and
gram-positive bacteria. Silver has minimal side effects and minimal
bacterial resistance. The other agents are applied topicall y and are not
activated by wound moisture.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Implementation TOP: Burns
MSC: NC LEX: Physiological Integrit y: Pharmacological
Therapies
3. A patient is admitted after being burned in a car fire. The wound surface
is red with patchy w hite areas that blanch with pressure but no blister
formation. What kind of burn would the nurse document in the patient’s
record?
a. Superficial partial -thickness burn
b. Moderate partial -thickness burn
c. Deep dermal partial -thickness burn
d. Full-thickness burn
, ANS: C
Deep-dermal partial-thickness (second -degree) burns involve the entire
epidermal layer and deeper layers of the dermis. A deep-dermal partial -
thickness burn usually is not characterized by blister formation. Onl y a
modest plasma surface leakage occu rs because of severe impairment in
blood suppl y. The wound surface usuall y is red with patchy white areas
that blanch with pressure.
PTS: 1 DIF: Cognitive Level: Understanding OBJ:
Nursing Process Step: Assessment TOP: Burns MSC:
NCLEX: Physiological Integrit y: Physiological Adaptation
4. A patient is brought to the emergency department after a house fire. He
fell asleep with a lit cigarette, and the couch ignited. What is the nurse’s
first priorit y?
a. Clean the wounds and remove blisters.
b. Assess the airway and provide 100% ox ygen.
c. Place a urinary drainage catheter and assess for m yoglobin.
d. Place a central intravenous access and provide antibiotics.
ANS: B
The first priorit y of emergency burn care is to secure and protect the
airway. All patients wi th major burns or suspected inhalation injury are
initiall y administered 100% ox ygen.
PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing
Process Step: Implementation TOP: Burns
