ATI RN 231 Med-Surg Quiz 4 Questions and
Correct Answers | 2026 Revised Update | 100%
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Question 1:
A nurse is caring for a client admitted to the emergency department with
gastroenteritis and partial and full-thickness burns of the head, neck, and chest. The
client is a 25-year-old male. The nurse should be aware that initially the client is at
greatest risk for:
a. Infection
b. Fluid imbalance
c. Airway obstruction
d. Paralytic ileus
Rationale: Burns of the head, neck, and chest may involve damage to the
pulmonary tree due to heat as well as smoke and soot inhalation. This can result in
severe respiratory difficulty. Using the ABCs (Airway, Breathing, Circulation),
airway obstruction is the priority concern. Nursing measures to maintain airway
patency must be initiated immediately.
Question 2:
A nurse is caring for a client who has full-thickness burns over 25% of his body.
Which of the following methods is appropriate to accurately monitor the
cardiovascular system?
a. Auscultate cuff blood pressure
b. Palpate pulse pressure
c. Obtain a central venous pressure
d. Monitor the pulmonary artery pressure
Rationale: Clients who have a large percentage of burned body surface area
require critical care and accurate monitoring. The pulmonary artery pressure
provides an accurate assessment of the cardiovascular system by detecting changes
,in left heart pressure, which can detect possible decompensation or pulmonary
edema. Cuff blood pressures are affected by peripheral vascular changes and often
lack a safe application site.
Question 3:
A client arrives at the emergency department following an explosion at a chemical
plant. He has deep partial- and full-thickness burns over more than 25% of his
body surface area. What is the most likely intervention for this client?
a. Initiate fluid resuscitation
b. Medicate for pain
c. Administer antimicrobials
d. Maintain a patent airway
Rationale: Since the client sustained burns to the chest, there is a possibility that
flames and smoke from the burning clothes could have caused an inhalation injury.
Using the airway, breathing, circulation (ABC) priorities, the priority concern at
this time is maintaining a patent airway.
Question 4:
A nurse in an emergency department is caring for a client who has burns on the
front and back of both his legs and arms. Using the rule of nines, the nurse should
document burns to which percentage of the client's total body surface area
(TBSA)?
a. 9 percent
b. 18 percent
c. 36 percent
d. 54 percent
Rationale: Each arm represents 9% of the client's TBSA (front and back combined
= 9%), and each leg represents 18% of the client's TBSA (front and back combined
= 18%). Both arms (9% × 2 = 18%) and both legs (18% × 2 = 36%) total 54%.
,Question 5:
A nurse is assessing a client who sustained burns to the anterior trunk and both
anterior arms. Using the rule of nines, what percentage of TBSA is burned?
a. 18%
b. 22.5%
c. 27%
d. 36%
Rationale: The anterior trunk represents 18% (9% anterior chest + 9% anterior
abdomen) and each anterior arm represents 4.5% (half of 9%). Total = 18% + 4.5%
+ 4.5% = 27%.
Question 6:
A client with burns to the lower extremities is at risk for which complication?
a. Deep vein thrombosis
b. Hypothermia
c. Hyperglycemia
d. Hypertension
Rationale: Burns to the lower extremities increase the risk of deep vein
thrombosis (DVT) due to immobility, venous stasis, and hypercoagulability.
Preventive measures include anticoagulation therapy and compression devices.
Question 7:
During the emergent phase of burn injury, which fluid is the priority for
resuscitation?
a. D5W
b. Lactated Ringer's solution
c. Normal saline
d. Albumin
Rationale: Lactated Ringer's solution is the fluid of choice for burn resuscitation
during the emergent phase. It is isotonic and helps replace lost fluid volume
without causing hyperchloremic acidosis.
, Question 8:
Which finding indicates the client is adequately resuscitated during the emergent
phase of burn care?
a. Heart rate >120/min
b. Urine output 30-50 mL/hr
c. Blood pressure 90/60 mmHg
d. Respiratory rate 28/min
Rationale: Adequate resuscitation is indicated by urine output of 30-50 mL/hr in
adults. This demonstrates that the kidneys are receiving adequate perfusion and
fluid resuscitation is effective.
Question 9:
A nurse is caring for a client with severe burns. Which finding indicates an
inhalation injury?
a. Normal breath sounds
b. Carbonaceous sputum and hoarseness
c. Bradycardia
d. Hypertension
Rationale: Carbonaceous sputum and hoarseness are signs of inhalation injury.
Other signs include singed nasal hairs, facial burns, and stridor. These findings
require immediate airway assessment and management.
Question 10:
What is the priority nursing intervention for a client with suspected inhalation
injury?
a. Administer oxygen via nasal cannula
b. Prepare for possible intubation
c. Administer pain medication
d. Begin fluid resuscitation
Rationale: Inhalation injury can cause rapid airway compromise due to edema.
The priority is to prepare for possible intubation to secure the airway. Early
intubation is recommended before edema makes intubation difficult.
Correct Answers | 2026 Revised Update | 100%
Correct | Comprehensive Review
Leave your honest rating⭐⭐⭐⭐⭐
Question 1:
A nurse is caring for a client admitted to the emergency department with
gastroenteritis and partial and full-thickness burns of the head, neck, and chest. The
client is a 25-year-old male. The nurse should be aware that initially the client is at
greatest risk for:
a. Infection
b. Fluid imbalance
c. Airway obstruction
d. Paralytic ileus
Rationale: Burns of the head, neck, and chest may involve damage to the
pulmonary tree due to heat as well as smoke and soot inhalation. This can result in
severe respiratory difficulty. Using the ABCs (Airway, Breathing, Circulation),
airway obstruction is the priority concern. Nursing measures to maintain airway
patency must be initiated immediately.
Question 2:
A nurse is caring for a client who has full-thickness burns over 25% of his body.
Which of the following methods is appropriate to accurately monitor the
cardiovascular system?
a. Auscultate cuff blood pressure
b. Palpate pulse pressure
c. Obtain a central venous pressure
d. Monitor the pulmonary artery pressure
Rationale: Clients who have a large percentage of burned body surface area
require critical care and accurate monitoring. The pulmonary artery pressure
provides an accurate assessment of the cardiovascular system by detecting changes
,in left heart pressure, which can detect possible decompensation or pulmonary
edema. Cuff blood pressures are affected by peripheral vascular changes and often
lack a safe application site.
Question 3:
A client arrives at the emergency department following an explosion at a chemical
plant. He has deep partial- and full-thickness burns over more than 25% of his
body surface area. What is the most likely intervention for this client?
a. Initiate fluid resuscitation
b. Medicate for pain
c. Administer antimicrobials
d. Maintain a patent airway
Rationale: Since the client sustained burns to the chest, there is a possibility that
flames and smoke from the burning clothes could have caused an inhalation injury.
Using the airway, breathing, circulation (ABC) priorities, the priority concern at
this time is maintaining a patent airway.
Question 4:
A nurse in an emergency department is caring for a client who has burns on the
front and back of both his legs and arms. Using the rule of nines, the nurse should
document burns to which percentage of the client's total body surface area
(TBSA)?
a. 9 percent
b. 18 percent
c. 36 percent
d. 54 percent
Rationale: Each arm represents 9% of the client's TBSA (front and back combined
= 9%), and each leg represents 18% of the client's TBSA (front and back combined
= 18%). Both arms (9% × 2 = 18%) and both legs (18% × 2 = 36%) total 54%.
,Question 5:
A nurse is assessing a client who sustained burns to the anterior trunk and both
anterior arms. Using the rule of nines, what percentage of TBSA is burned?
a. 18%
b. 22.5%
c. 27%
d. 36%
Rationale: The anterior trunk represents 18% (9% anterior chest + 9% anterior
abdomen) and each anterior arm represents 4.5% (half of 9%). Total = 18% + 4.5%
+ 4.5% = 27%.
Question 6:
A client with burns to the lower extremities is at risk for which complication?
a. Deep vein thrombosis
b. Hypothermia
c. Hyperglycemia
d. Hypertension
Rationale: Burns to the lower extremities increase the risk of deep vein
thrombosis (DVT) due to immobility, venous stasis, and hypercoagulability.
Preventive measures include anticoagulation therapy and compression devices.
Question 7:
During the emergent phase of burn injury, which fluid is the priority for
resuscitation?
a. D5W
b. Lactated Ringer's solution
c. Normal saline
d. Albumin
Rationale: Lactated Ringer's solution is the fluid of choice for burn resuscitation
during the emergent phase. It is isotonic and helps replace lost fluid volume
without causing hyperchloremic acidosis.
, Question 8:
Which finding indicates the client is adequately resuscitated during the emergent
phase of burn care?
a. Heart rate >120/min
b. Urine output 30-50 mL/hr
c. Blood pressure 90/60 mmHg
d. Respiratory rate 28/min
Rationale: Adequate resuscitation is indicated by urine output of 30-50 mL/hr in
adults. This demonstrates that the kidneys are receiving adequate perfusion and
fluid resuscitation is effective.
Question 9:
A nurse is caring for a client with severe burns. Which finding indicates an
inhalation injury?
a. Normal breath sounds
b. Carbonaceous sputum and hoarseness
c. Bradycardia
d. Hypertension
Rationale: Carbonaceous sputum and hoarseness are signs of inhalation injury.
Other signs include singed nasal hairs, facial burns, and stridor. These findings
require immediate airway assessment and management.
Question 10:
What is the priority nursing intervention for a client with suspected inhalation
injury?
a. Administer oxygen via nasal cannula
b. Prepare for possible intubation
c. Administer pain medication
d. Begin fluid resuscitation
Rationale: Inhalation injury can cause rapid airway compromise due to edema.
The priority is to prepare for possible intubation to secure the airway. Early
intubation is recommended before edema makes intubation difficult.
