Lewis's Medical-Surgical Nursing: Assessment and
Management of Clinical Problems, Single Volume
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 the results and continue to monitor the patients respiratory rate.
d. Reposition the patient in high-Fowlers position and reassess breath sounds.
ANS: B
The patients history and clinical manifestations suggest airway edema and the health
care provider should be notified immediately, so that intubation can be done rapidly.
Placing the patient in a more upright position or having the patient cough will not
address the problem of airway edema. Continuing to monitor is inappropriate
because immediate action should occur.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. Apatient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be administered in the first 24
hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first
8 hours, what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250
,mL/hour
ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first
8 hours and the other half over the next 16 hours. In this case, the patient should
receive half of the initial rate, or 938 mL/hr.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. Duringthe emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1
mL/kg/hour. The patients weight is not useful in this situation because of the
effects of third spacing and evaporative fluid loss. Mucous membrane assessment
and skin turgor also may be used, but they are not as adequate in determining that
fluid infusions are maintaining adequate perfusion.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. A patient has just been admitted with a 40% total body surface area (TBSA)
burn injury. To maintain adequate nutrition, the nurse should plan to take
which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
ANS: A
, Enteral feedings can usually be initiated during the emergent phase at low rates
and increased over 24 to 48 hours to the goal rate. During the emergent phase, the
patient will be unable to eat enough calories to meet nutritional needs and may
have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and
minerals may be administered during the emergent phase, but these will not assist
in meeting the patients caloric needs. Parenteral nutrition increases the infection
risk, does not help preserve gastrointestinal function, and is not routinely used in
burn patients.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. While the patients fullthickness burn wounds to the face are exposed, what is
the best nursing action to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70 F (20 C) during dressing
changes.
ANS: B
Use of gowns, caps, masks, and gloves during all patient care will decrease the
possibility of wound contamination for a patient whose burns are not covered. When
removing contaminated dressings and washing the dirty wound, use nonsterile,
disposable gloves. The room temperature should be kept at approximately 85 F for
patients with open burn wounds to prevent shivering. Systemic antibiotics are not
well absorbed into deep burns because of the lack of circulation.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. Anurse is caring for a patient who has burns of the ears, head, neck, and
right arm and hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
Management of Clinical Problems, Single Volume
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 the results and continue to monitor the patients respiratory rate.
d. Reposition the patient in high-Fowlers position and reassess breath sounds.
ANS: B
The patients history and clinical manifestations suggest airway edema and the health
care provider should be notified immediately, so that intubation can be done rapidly.
Placing the patient in a more upright position or having the patient cough will not
address the problem of airway edema. Continuing to monitor is inappropriate
because immediate action should occur.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. Apatient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be administered in the first 24
hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first
8 hours, what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250
,mL/hour
ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first
8 hours and the other half over the next 16 hours. In this case, the patient should
receive half of the initial rate, or 938 mL/hr.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. Duringthe emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1
mL/kg/hour. The patients weight is not useful in this situation because of the
effects of third spacing and evaporative fluid loss. Mucous membrane assessment
and skin turgor also may be used, but they are not as adequate in determining that
fluid infusions are maintaining adequate perfusion.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. A patient has just been admitted with a 40% total body surface area (TBSA)
burn injury. To maintain adequate nutrition, the nurse should plan to take
which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
ANS: A
, Enteral feedings can usually be initiated during the emergent phase at low rates
and increased over 24 to 48 hours to the goal rate. During the emergent phase, the
patient will be unable to eat enough calories to meet nutritional needs and may
have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and
minerals may be administered during the emergent phase, but these will not assist
in meeting the patients caloric needs. Parenteral nutrition increases the infection
risk, does not help preserve gastrointestinal function, and is not routinely used in
burn patients.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. While the patients fullthickness burn wounds to the face are exposed, what is
the best nursing action to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70 F (20 C) during dressing
changes.
ANS: B
Use of gowns, caps, masks, and gloves during all patient care will decrease the
possibility of wound contamination for a patient whose burns are not covered. When
removing contaminated dressings and washing the dirty wound, use nonsterile,
disposable gloves. The room temperature should be kept at approximately 85 F for
patients with open burn wounds to prevent shivering. Systemic antibiotics are not
well absorbed into deep burns because of the lack of circulation.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. Anurse is caring for a patient who has burns of the ears, head, neck, and
right arm and hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
