TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING
11 TH EDITION BY HARDING 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 the results and continue to monitor the patients respiratory rate.
d. Reposition the patient in high-Fowlers position and reassess breath sounds.
ANS: B
The patients 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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250
mL/hour 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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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.
11 TH EDITION BY HARDING 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 the results and continue to monitor the patients respiratory rate.
d. Reposition the patient in high-Fowlers position and reassess breath sounds.
ANS: B
The patients 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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250
mL/hour 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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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.
