TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING
11TH EDITION BYHARDING Questions & Answers
satisfaction guaranteed success ( CHAPTERS 21-29)
latest update
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 athe aresults aand acontinue ato amonitor athe apatients
respiratory arate.
a
d. Reposition athe apatient ain ahigh-Fowlers aposition aand areassess abreath
sounds.
a
ANS: aB
The apatients ahistory aand aclinical amanifestations asuggest aairway aedema aand
the ahealth acare aprovider ashould abe anotified aimmediately, aso athat aintubation
a
can abe adone arapidly. aPlacing athe apatient ain aa amore aupright aposition aor
a
a having athe apatient acough awill anot aaddress athe aproblem aof aairway aedema.
Continuing ato amonitor ais ainappropriateabecause aimmediate aaction ashould
a
occur.
a
DIF: aCognitive aLevel: aApply a(application)
, TOP: a Nursing a Process: a Implementation a MSC: a NCLEX: a Physiological
a Integrity
4. A apatient awith asevere aburns ahas acrystalloid afluid areplacement aordered
using athe aParkland aformula. aThe ainitial avolume aof afluid ato abe
a
administered ain athe afirst a24 ahours ais a30,000 amL. aThe ainitial arate aof
a
administration ais a1875 amL/hr. aAfter athe afirst a8 ahours, awhat arate ashould
a
the anurse ainfuse athe aIV afluids?
a
a. 350 a mL/hour
b. 523 a mL/hour
c. 938 a mL/hour
d. 1250
a mL/houraANS: aC
Half aof athe afluid areplacement ausing athe aParkland aformula ais aadministered ain
the afirst a8 ahours aand athe aother ahalfaover athe anext a16 ahours. aIn athis acase,
a
the apatient ashould areceive ahalf aof athe ainitial arate, aor a938 amL/hr.
a
DIF: aCognitive aLevel: aApply a(application)
TOP: a Nursing a Process: a Implementation a MSC: a NCLEX: a Physiological
a Integrity
5. During a the a emergent a phase a of a burn a care, a which a assessment a will a be
most a useful a in a determining a whether a the apatient ais areceiving aadequate
a
a fluid ainfusion?
11TH EDITION BYHARDING Questions & Answers
satisfaction guaranteed success ( CHAPTERS 21-29)
latest update
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 athe aresults aand acontinue ato amonitor athe apatients
respiratory arate.
a
d. Reposition athe apatient ain ahigh-Fowlers aposition aand areassess abreath
sounds.
a
ANS: aB
The apatients ahistory aand aclinical amanifestations asuggest aairway aedema aand
the ahealth acare aprovider ashould abe anotified aimmediately, aso athat aintubation
a
can abe adone arapidly. aPlacing athe apatient ain aa amore aupright aposition aor
a
a having athe apatient acough awill anot aaddress athe aproblem aof aairway aedema.
Continuing ato amonitor ais ainappropriateabecause aimmediate aaction ashould
a
occur.
a
DIF: aCognitive aLevel: aApply a(application)
, TOP: a Nursing a Process: a Implementation a MSC: a NCLEX: a Physiological
a Integrity
4. A apatient awith asevere aburns ahas acrystalloid afluid areplacement aordered
using athe aParkland aformula. aThe ainitial avolume aof afluid ato abe
a
administered ain athe afirst a24 ahours ais a30,000 amL. aThe ainitial arate aof
a
administration ais a1875 amL/hr. aAfter athe afirst a8 ahours, awhat arate ashould
a
the anurse ainfuse athe aIV afluids?
a
a. 350 a mL/hour
b. 523 a mL/hour
c. 938 a mL/hour
d. 1250
a mL/houraANS: aC
Half aof athe afluid areplacement ausing athe aParkland aformula ais aadministered ain
the afirst a8 ahours aand athe aother ahalfaover athe anext a16 ahours. aIn athis acase,
a
the apatient ashould areceive ahalf aof athe ainitial arate, aor a938 amL/hr.
a
DIF: aCognitive aLevel: aApply a(application)
TOP: a Nursing a Process: a Implementation a MSC: a NCLEX: a Physiological
a Integrity
5. During a the a emergent a phase a of a burn a care, a which a assessment a will a be
most a useful a in a determining a whether a the apatient ais areceiving aadequate
a
a fluid ainfusion?
