: Burns Lewis: Medical-Surgical Nursing
When assessing a patient who spilled hot oil on the right leg and foot, the
nurse
dry, notes
pale, and hard skin. The patient states that the burn is not painful. What
termnurse
the would 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
answers B
On admission to the burn unit, a patient with an approximate 25% total
body (TBSA)
area surfaceburn 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. correct
answers C
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 Encourage
a. take? 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
d. Reposition rate.
the patient in high-Fowler's position and reassess breath
sounds. correct
answers
B
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
The mL.rate of administration is 1875 mL/hr. After the first 8 hours, what
initial
ratenurse
the should infuse the IV
a. 219 mL/hr c. 938
fluids?
mL/hr
b. 625 mL/hr d. 1875 mL/hr correct
answers C
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
answers D
A patient has just been admitted with a 40% total body surface area (TBSA)
burn
To injury. adequate nutrition, the nurse should plan to take
maintain
which action?
, 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
answers B
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 Give
d. times. IV antibiotics to prevent bacterial colonization of wounds. correct
answers B
A nurse is caring for a patient who has burns of the ears, head, neck, and
right arm
hand. Theandnurse should place the patient in which
position?
a. Place the right arm and hand flexed in a position of
comfort.
b. Elevate the right arm and hand on pillows and extend
the fingers.
c. Assist the patient to a supine position with a small pillow under
thePosition
d. head. the patient in a side-lying position with rolled towel under the
neck. correct
answers
B
A patient with circumferential burns of both legs develops a decrease in
dorsalis
pulse pedis and numbness in the toes. Which action should the nurse
strength
take
a. first? the pulses every
Monitor
hour.
b. Notify the health care
provider.
c. Elevate both legs above heart level with
pillows.
d. Encourage the patient to flex and extend the toes. correct
answers B
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive
burn
5 daysinjuries
ago. Which nursing assessment would best evaluate the
effectiveness of the
drug
a. Bowel sounds c. Stool occult
?
blood
b. Stool frequency d. Abdominal distention correct
answers C
Which prescribed drug is best for the nurse to give before
scheduled wound
debridement on a patient with partial-thickness
burns?
a. ketorolac c. gabapentin
b. lorazepam (Ativan) d. hydromorphone (Dilaudid) correct
(Neurontin)
answers D
A young adult patient who is in the rehabilitation phase after having
deep partial-
thickness face and neck burns has a nursing diagnosis of disturbed body
image. Which
statement by the patient best indicates that the problem is
resolving?
a. "I'm glad the scars are only
temporary."
b. "I will avoid using a pillow, so my neck will
be"Do
c. OK."you think dark beige makeup will cover this
scar?"
d. "I don't think my boyfriend will want to look at me now." correct
answers C
When assessing a patient who spilled hot oil on the right leg and foot, the
nurse
dry, notes
pale, and hard skin. The patient states that the burn is not painful. What
termnurse
the would 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
answers B
On admission to the burn unit, a patient with an approximate 25% total
body (TBSA)
area surfaceburn 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. correct
answers C
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 Encourage
a. take? 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
d. Reposition rate.
the patient in high-Fowler's position and reassess breath
sounds. correct
answers
B
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
The mL.rate of administration is 1875 mL/hr. After the first 8 hours, what
initial
ratenurse
the should infuse the IV
a. 219 mL/hr c. 938
fluids?
mL/hr
b. 625 mL/hr d. 1875 mL/hr correct
answers C
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
answers D
A patient has just been admitted with a 40% total body surface area (TBSA)
burn
To injury. adequate nutrition, the nurse should plan to take
maintain
which action?
, 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
answers B
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 Give
d. times. IV antibiotics to prevent bacterial colonization of wounds. correct
answers B
A nurse is caring for a patient who has burns of the ears, head, neck, and
right arm
hand. Theandnurse should place the patient in which
position?
a. Place the right arm and hand flexed in a position of
comfort.
b. Elevate the right arm and hand on pillows and extend
the fingers.
c. Assist the patient to a supine position with a small pillow under
thePosition
d. head. the patient in a side-lying position with rolled towel under the
neck. correct
answers
B
A patient with circumferential burns of both legs develops a decrease in
dorsalis
pulse pedis and numbness in the toes. Which action should the nurse
strength
take
a. first? the pulses every
Monitor
hour.
b. Notify the health care
provider.
c. Elevate both legs above heart level with
pillows.
d. Encourage the patient to flex and extend the toes. correct
answers B
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive
burn
5 daysinjuries
ago. Which nursing assessment would best evaluate the
effectiveness of the
drug
a. Bowel sounds c. Stool occult
?
blood
b. Stool frequency d. Abdominal distention correct
answers C
Which prescribed drug is best for the nurse to give before
scheduled wound
debridement on a patient with partial-thickness
burns?
a. ketorolac c. gabapentin
b. lorazepam (Ativan) d. hydromorphone (Dilaudid) correct
(Neurontin)
answers D
A young adult patient who is in the rehabilitation phase after having
deep partial-
thickness face and neck burns has a nursing diagnosis of disturbed body
image. Which
statement by the patient best indicates that the problem is
resolving?
a. "I'm glad the scars are only
temporary."
b. "I will avoid using a pillow, so my neck will
be"Do
c. OK."you think dark beige makeup will cover this
scar?"
d. "I don't think my boyfriend will want to look at me now." correct
answers C
