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 dthe dresults dand dcontinue dto dmonitor dthe dpatients
respiratory drate.
d
d. Reposition dthe dpatient din dhigh-Fowlers dposition dand dreassess dbreath
sounds.
d
ANS: dB
The dpatients dhistory dand dclinical dmanifestations dsuggest dairway dedema dand
the dhealth dcare dprovider dshould dbe dnotified dimmediately, dso dthat
d
intubation dcan dbe ddone drapidly. dPlacing dthe dpatient din da dmore dupright
d
position dor dhaving dthe dpatient dcough dwill dnot daddress dthe dproblem dof
d
airway dedema. dContinuing dto dmonitor dis dinappropriatedbecause dimmediate
d
action dshould doccur.
d
DIF: dCognitive dLevel: dApply d(application)
, TOP: d Nursing d Process: d Implementation d MSC: d NCLEX: d Physiological
d Integrity
4. A dpatient dwith dsevere dburns dhas dcrystalloid dfluid dreplacement dordered
using dthe dParkland dformula. dThe dinitial dvolume dof dfluid dto dbe
d
administered din dthe dfirst d24 dhours dis d30,000 dmL. dThe dinitial drate dof
d
administration dis d1875 dmL/hr. dAfter dthe dfirst d8 dhours, dwhat drate dshould
d
the dnurse dinfuse dthe dIV dfluids?
d
a. 350 d mL/hour
b. 523 d mL/hour
c. 938 d mL/hour
d. 1250
d mL/hourdANS: dC
Half dof dthe dfluid dreplacement dusing dthe dParkland dformula dis dadministered
in dthe dfirst d8 dhours dand dthe dother dhalfdover dthe dnext d16 dhours. dIn dthis
d
case, dthe dpatient dshould dreceive dhalf dof dthe dinitial drate, dor d938 dmL/hr.
d
DIF: dCognitive dLevel: dApply d(application)
TOP: d Nursing d Process: d Implementation d MSC: d NCLEX: d Physiological
d Integrity
5. During d the d emergent d phase d of d burn d care, d which d assessment d will d be
most d useful d in d determining d whether d the dpatient dis dreceiving dadequate
d
d fluid dinfusion?
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 dthe dresults dand dcontinue dto dmonitor dthe dpatients
respiratory drate.
d
d. Reposition dthe dpatient din dhigh-Fowlers dposition dand dreassess dbreath
sounds.
d
ANS: dB
The dpatients dhistory dand dclinical dmanifestations dsuggest dairway dedema dand
the dhealth dcare dprovider dshould dbe dnotified dimmediately, dso dthat
d
intubation dcan dbe ddone drapidly. dPlacing dthe dpatient din da dmore dupright
d
position dor dhaving dthe dpatient dcough dwill dnot daddress dthe dproblem dof
d
airway dedema. dContinuing dto dmonitor dis dinappropriatedbecause dimmediate
d
action dshould doccur.
d
DIF: dCognitive dLevel: dApply d(application)
, TOP: d Nursing d Process: d Implementation d MSC: d NCLEX: d Physiological
d Integrity
4. A dpatient dwith dsevere dburns dhas dcrystalloid dfluid dreplacement dordered
using dthe dParkland dformula. dThe dinitial dvolume dof dfluid dto dbe
d
administered din dthe dfirst d24 dhours dis d30,000 dmL. dThe dinitial drate dof
d
administration dis d1875 dmL/hr. dAfter dthe dfirst d8 dhours, dwhat drate dshould
d
the dnurse dinfuse dthe dIV dfluids?
d
a. 350 d mL/hour
b. 523 d mL/hour
c. 938 d mL/hour
d. 1250
d mL/hourdANS: dC
Half dof dthe dfluid dreplacement dusing dthe dParkland dformula dis dadministered
in dthe dfirst d8 dhours dand dthe dother dhalfdover dthe dnext d16 dhours. dIn dthis
d
case, dthe dpatient dshould dreceive dhalf dof dthe dinitial drate, dor d938 dmL/hr.
d
DIF: dCognitive dLevel: dApply d(application)
TOP: d Nursing d Process: d Implementation d MSC: d NCLEX: d Physiological
d Integrity
5. During d the d emergent d phase d of d burn d care, d which d assessment d will d be
most d useful d in d determining d whether d the dpatient dis dreceiving dadequate
d
d fluid dinfusion?
