TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING
11TH EDITION BYHARDING Questions & Answers
satisfaction guaranteed success ( CHAPTERS 21-29)
latest update
Chapter 21: Burns
Test Bank
MULTIPLE
CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the
nurse notes that the skin is dry, pale, hard skin. The patient states that the
burn is not painful. What term would the nurse use to document the burn
depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness
skin destruction ANS: B
With full-thickness skin destruction, the appearance is pale and dry or
leathery and the area is painless because of the associated nerve destruction.
Erythema, swelling, 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 exhibit erythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension)
,TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. On admission to the burn unit, a patient with an approximate 25% total
body surface area (TBSA) burn has the following initial laboratory results:
Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L),
and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse
anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
The patients laboratory data show hemoconcentration, which may lead to a
decrease in blood flow to the microcirculation unless fluid intake is
increased. Because the hematocrit and hemoglobin are elevated, a
transfusion is inappropriate, although transfusions may be needed after the
emergent phase once the patients fluid balance has been restored. On
admission to a burn unit, the urine output would be monitored more often
than every 4 hours; likely every1 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
hands. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. What is the best action for the nurse
to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal
intubation.
c. Document sthe sresults sand scontinue sto smonitor sthe spatients
respiratory srate.
s
d. Reposition sthe spatient sin shigh-Fowlers sposition sand sreassess sbreath
sounds.
s
ANS: sB
The spatients shistory sand sclinical smanifestations ssuggest sairway sedema sand
the shealth scare sprovider sshould sbe snotified simmediately, sso sthat sintubation
s
can sbe sdone srapidly. sPlacing sthe spatient sin sa smore supright sposition sor
s
s having sthe spatient scough swill snot saddress sthe sproblem sof sairway sedema.
Continuing sto smonitor sis sinappropriatesbecause simmediate saction sshould
s
occur.
s
DIF: sCognitive sLevel: sApply s(application)
, TOP: s Nursing s Process: s Implementation s MSC: s NCLEX: s Physiological
s Integrity
4. A patient swith ssevere sburns shas scrystalloid sfluid sreplacement sordered
s
using sthe sParkland sformula. sThe sinitial svolume sof sfluid sto sbe sadministered
s
in sthe sfirst s24 shours sis s30,000 smL. sThe sinitial srate sof sadministration sis s1875
s
s mL/hr. sAfter sthe sfirst s8 shours, swhat srate sshould sthe snurse sinfuse sthe sIV
fluids?
s
a. 350 s mL/hour
b. 523 s mL/hour
c. 938 s mL/hour
d. 1250
s mL/hoursANS: sC
Half sof sthe sfluid sreplacement susing sthe sParkland sformula sis sadministered sin
the sfirst s8 shours sand sthe sother shalfsover sthe snext s16 shours. sIn sthis scase, sthe
s
patient sshould sreceive shalf sof sthe sinitial srate, sor s938 smL/hr.
s
DIF: sCognitive sLevel: sApply s(application)
TOP: s Nursing s Process: s Implementation s MSC: s NCLEX: s Physiological
s Integrity
5. During s the s emergent s phase s of s burn s care, s which s assessment s will s be smost
s useful s in s determining s whether s the spatient sis sreceiving sadequate sfluid
infusion?
s
11TH EDITION BYHARDING Questions & Answers
satisfaction guaranteed success ( CHAPTERS 21-29)
latest update
Chapter 21: Burns
Test Bank
MULTIPLE
CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the
nurse notes that the skin is dry, pale, hard skin. The patient states that the
burn is not painful. What term would the nurse use to document the burn
depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness
skin destruction ANS: B
With full-thickness skin destruction, the appearance is pale and dry or
leathery and the area is painless because of the associated nerve destruction.
Erythema, swelling, 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 exhibit erythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension)
,TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. On admission to the burn unit, a patient with an approximate 25% total
body surface area (TBSA) burn has the following initial laboratory results:
Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L),
and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse
anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
The patients laboratory data show hemoconcentration, which may lead to a
decrease in blood flow to the microcirculation unless fluid intake is
increased. Because the hematocrit and hemoglobin are elevated, a
transfusion is inappropriate, although transfusions may be needed after the
emergent phase once the patients fluid balance has been restored. On
admission to a burn unit, the urine output would be monitored more often
than every 4 hours; likely every1 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
hands. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. What is the best action for the nurse
to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal
intubation.
c. Document sthe sresults sand scontinue sto smonitor sthe spatients
respiratory srate.
s
d. Reposition sthe spatient sin shigh-Fowlers sposition sand sreassess sbreath
sounds.
s
ANS: sB
The spatients shistory sand sclinical smanifestations ssuggest sairway sedema sand
the shealth scare sprovider sshould sbe snotified simmediately, sso sthat sintubation
s
can sbe sdone srapidly. sPlacing sthe spatient sin sa smore supright sposition sor
s
s having sthe spatient scough swill snot saddress sthe sproblem sof sairway sedema.
Continuing sto smonitor sis sinappropriatesbecause simmediate saction sshould
s
occur.
s
DIF: sCognitive sLevel: sApply s(application)
, TOP: s Nursing s Process: s Implementation s MSC: s NCLEX: s Physiological
s Integrity
4. A patient swith ssevere sburns shas scrystalloid sfluid sreplacement sordered
s
using sthe sParkland sformula. sThe sinitial svolume sof sfluid sto sbe sadministered
s
in sthe sfirst s24 shours sis s30,000 smL. sThe sinitial srate sof sadministration sis s1875
s
s mL/hr. sAfter sthe sfirst s8 shours, swhat srate sshould sthe snurse sinfuse sthe sIV
fluids?
s
a. 350 s mL/hour
b. 523 s mL/hour
c. 938 s mL/hour
d. 1250
s mL/hoursANS: sC
Half sof sthe sfluid sreplacement susing sthe sParkland sformula sis sadministered sin
the sfirst s8 shours sand sthe sother shalfsover sthe snext s16 shours. sIn sthis scase, sthe
s
patient sshould sreceive shalf sof sthe sinitial srate, sor s938 smL/hr.
s
DIF: sCognitive sLevel: sApply s(application)
TOP: s Nursing s Process: s Implementation s MSC: s NCLEX: s Physiological
s Integrity
5. During s the s emergent s phase s of s burn s care, s which s assessment s will s be smost
s useful s in s determining s whether s the spatient sis sreceiving sadequate sfluid
infusion?
s
