NU 185 EXAM 3 -MED SURG NURSING II |ACTUAL
QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
2026-2027 UPDATE|GRADED A+
Question 1
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry,
pale, and 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
CORRECT ANSWER
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.
Question 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 of the
following prescribed actions should be the nurse's priority?
a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion.
1
,CORRECT ANSWER
ANS: C
The patient's laboratory results 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 patient's 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).
Question 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 patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
CORRECT ANSWER
ANS: B
The patient's 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.
Question 4
A patient 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?
2
,a. 219 mL/hr
c. 938 mL/hr
b. 625 mL/hr
d. 1875 mL/hr
CORRECT ANSWER
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.
Question 5
During the 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.
c. Assess mucous membranes.
b. Monitor daily weight.
d. Measure hourly urine output.
CORRECT ANSWER
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The
patient's 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.
Question 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?
3
, a. Administer vitamins and minerals intravenously.
b. Insert a feeding tube and initiate enteral feedings.
c. Infuse total parenteral nutrition via a central catheter.
d. Encourage an oral intake of at least 5000 kcal per day.
CORRECT ANSWER
ANS: B
Enteral feedings can usually be started 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
patient's caloric needs. Parenteral nutrition increases the infection risk, does not help
preserve gastrointestinal function, and is not routinely used in burn patients unless the
gastrointestinal tract is not available for use.
Question 7
While the patient's full-thickness burn wounds to the face are exposed, what nursing
action prevents cross contamination?
a. Use sterile gloves when removing dressings.
b. Wear gown, cap, mask, and gloves during care.
c. Keep the room temperature at 70° F (20° C) at all times.
d. Give IV antibiotics to prevent bacterial colonization of wounds.
CORRECT ANSWER
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.
4
QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
2026-2027 UPDATE|GRADED A+
Question 1
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry,
pale, and 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
CORRECT ANSWER
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.
Question 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 of the
following prescribed actions should be the nurse's priority?
a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion.
1
,CORRECT ANSWER
ANS: C
The patient's laboratory results 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 patient's 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).
Question 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 patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
CORRECT ANSWER
ANS: B
The patient's 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.
Question 4
A patient 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?
2
,a. 219 mL/hr
c. 938 mL/hr
b. 625 mL/hr
d. 1875 mL/hr
CORRECT ANSWER
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.
Question 5
During the 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.
c. Assess mucous membranes.
b. Monitor daily weight.
d. Measure hourly urine output.
CORRECT ANSWER
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The
patient's 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.
Question 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?
3
, a. Administer vitamins and minerals intravenously.
b. Insert a feeding tube and initiate enteral feedings.
c. Infuse total parenteral nutrition via a central catheter.
d. Encourage an oral intake of at least 5000 kcal per day.
CORRECT ANSWER
ANS: B
Enteral feedings can usually be started 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
patient's caloric needs. Parenteral nutrition increases the infection risk, does not help
preserve gastrointestinal function, and is not routinely used in burn patients unless the
gastrointestinal tract is not available for use.
Question 7
While the patient's full-thickness burn wounds to the face are exposed, what nursing
action prevents cross contamination?
a. Use sterile gloves when removing dressings.
b. Wear gown, cap, mask, and gloves during care.
c. Keep the room temperature at 70° F (20° C) at all times.
d. Give IV antibiotics to prevent bacterial colonization of wounds.
CORRECT ANSWER
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.
4
