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
urse notes that the skin is dry, pale, hard skin. The patient states that the bu
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
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 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
2. On admission to the burn unit, a patient with an approximate 25% total b
ody surface area (TBSA) burn hasthe following initial laboratory results: H
ct 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 t
aking 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 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
e urine output would be monitored more oftenthan every 4 hours; likely ever
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
reased 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 intubatio
n.
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
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
urse notes that the skin is dry, pale, hard skin. The patient states that the bu
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
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 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
2. On admission to the burn unit, a patient with an approximate 25% total b
ody surface area (TBSA) burn hasthe following initial laboratory results: H
ct 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 t
aking 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 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
e urine output would be monitored more oftenthan every 4 hours; likely ever
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
reased 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 intubatio
n.
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
