BSN 266 (Review HESI) with all Correct & 100% Verified
Answers |Actual Complete Exam| Already Graded A+
(Just Released)
Overview of Burn Injuries:
A nurse is caring for a patient who spilled boiling soup on her legs. Which type of burn will the nurse
see?
Thermal
Electrical
Chemical
Smoke inhalation ✔Correct Answer-Thermal
Thermal burns are caused by flame, flash, scald, or contact with hot objects (such as boiling soup).
Question 2 of 6
A family member of a patient with a severe facial burn asks the nurse why the patient's face is
swollen. Which statement made by the nurse is appropriate?
"Swelling is an expected inflammatory response of the body to a burn injury."
"Swelling occurs when a person is allergic to the substance that caused the burn."
"Moderate swelling is an expected side effect of the pain medications we are giving."
"Some swelling is expected during treatment because the patient has been lying down and resting."
✔Correct Answer-"Swelling is an expected inflammatory response of the body to a burn injury."
Swelling is expected after a burn injury because of increased capillary permeability, which results in
leakage of fluids and electrolytes into the interstitium.
Question 3 of 6
A student nurse is caring for a patient with severe thermal burns. Which statement made by the
student nurse to the charge nurse indicates that additional teaching is needed?
"I will assess my patient regularly for pain and anxiety."
"An inflammatory response is necessary for the body to begin the healing process."
"The severity of my patient's burns is a result of the temperature of the burning agent and the
contact time."
"I will check my patient hourly to make sure that he does not experience an inflammatory response
from his burns." ✔Correct Answer-"I will check my patient hourly to make sure that he does not
experience an inflammatory response from his burns."
An inflammatory response is expected after a burn injury and is necessary for the healing process to
begin. The nursing student needs additional teaching about the role of an inflammatory response in
the healing process.
Question 4 of 6
A nurse is caring for a patient with a first-degree thermal burn injury. Which symptom can the nurse
expect to see on assessment?
Insensitivity to pain
Cherry-red skin color
Blanching with pressure
Edema of surrounding tissue ✔Correct Answer-Blanching with pressure
Blanching with pressure is an expected clinical manifestation of a partial-thickness superficial (first-
degree) thermal burn injury.
,Question 5 of 6
What is the proper classification for a thermal burn involving only the epidermis and superficial
structures of the dermis?
Superficial burn
Deep tissue burn
Full-thickness burn
Partial-thickness burn ✔Correct Answer-Partial-thickness burn
A partial-thickness burn involves the epidermis and the superficial structures of the dermis.
Question 6 of 6
When calculating the total body surface area (TBSA) affected by a burn, the nurse knows that the
Lund-Browder chart is considered more accurate than the rule of nines for which reason?
The rule of nines does not include burns to the chest in calculation of TBSA.
The Lund-Browder chart considers the age of the patient in calculation of TBSA.
The rule of nines does not consider the size of the patient in calculation of TBSA.
The Lund-Browder chart considers the weight of the patient in calculation of TBSA. ✔Correct
Answer-The Lund-Browder chart considers the age of the patient in calculation of TBSA.
The Lund-Browder chart considers the age of the patient in calculation of TBSA. The rule of nines
does not consider the age of the patient in the calculation.
Collaborative Care and Nursing Management of Burn Injuries:
Question 1 of 6
A nurse is caring for a newly admitted patient in the emergent phase after a severe electrical burn.
Which provider orders should the nurse question?
Obtain an ECG in 8 hours
Administer PO pain medication
Insert large-bore IV to provide fluids
Contact anesthesiologist to begin intubation ✔Correct Answer-Obtain an ECG in 8 hours
The patient should have an ECG performed now, not delayed for 8 hours. The patient with an
electrical burn injury is at risk for cardiac dysrhythmias. The nurse should question this provider
order.
Administer PO pain medication
Patients in the emergent phase of burn management should be treated for pain, but PO is not an
appropriate management technique because pain medications will be administered intravenously.
The nurse should question this provider order.
Question 2 of 6
A nurse is caring for a patient with a chemical burn to the left extremity who is in the rehabilitative
phase of burn management. Which order would the nurse anticipate from the health care provider?
Begin IV pain medications
Provide patient education on wound care
Continue a low-calorie diet to support wound healing
Provide information on obtaining home oxygen services ✔Correct Answer-Provide patient
education on wound care
The rehabilitation phase begins when the patient's wounds are healed and he or she is engaging in
some form of self-care. It is appropriate to provide the patient with education on wound care during
this phase.
Question 3 of 6
What is the total 24-hour fluid requirement in milliliters for a 55-kg adult patient with 75% TBSA
burned? ✔Correct Answer-16500
,4 mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface
area (% TBSA) burned = Total fluid requirements for first 24 hours after burn
4 mL × 55 kg × 75 = 16500 mL
Question 4 of 6
The nurse is caring for a patient who was just transported by EMS to the hospital for burns to the
legs, chest, arms, and face. Which nursing interventions are appropriate at this time?
Select all that apply.
Prepare to initiate tube feeding as indicated
Insert urinary catheter to monitor intake and output
Administer oral analgesic of acetaminophen 650 mg
Discuss home care and rehabilitation with the patient's family
Monitor oxygen status and provide supplemental oxygen as needed ✔Correct Answer-Insert
urinary catheter to monitor intake and output
The nurse is caring for a patient in the emergent phase of burn management. It is appropriate to
insert a catheter to monitor the intake and output during this phase to effectively assess fluid status.
Monitor oxygen status and provide supplemental oxygen as needed
The nurse is assessing a patient in the emergent phase of burn management. It is appropriate to
monitor oxygen and provide supplemental oxygen as needed because the patient may be at risk for
impaired perfusion and ventilation.
Question 5 of 6
A patient is admitted to the burn center with burns to the neck and chest after a gasoline explosion
at work. Emergency transport reported wheezing in the upper lung fields. Upon initial assessment,
the nurse notes no current wheezing and diminished breath sounds throughout. What is the
appropriate action for the nurse to take?
Check vital signs and obtain arterial blood gas values.
Sit the patient upright and encourage deep breathing.
Contact the health care provider and prepare for emergency intubation.
Continue with the assessment, observing for edema and cardiac output. ✔Correct Answer-Contact
the health care provider and prepare for emergency intubation.
The patient is likely to have inhalation burn injuries, and intubation is necessary to maintain
oxygenation and ventilation.
Question 6 of 6
A patient with facial burns frequently asks the nurse, "When will I look normal again?" Which is an
appropriate response by the nurse?
"You seem to be very anxious. Would you like to talk about how you're feeling?"
"It's okay to be afraid of how your face looks now, but it will get better with time."
"I noticed that you've been asking this question often. Are you feeling depressed?"
"You will likely need to have some reconstructive treatment before seeing an improvement."
✔Correct Answer-"You seem to be very anxious. Would you like to talk about how you're feeling?"
The patient is verbally expressing signs of anxiety. The nurse should attend to the patient's
psychologic and emotional needs at this time.
Transplantation-Week 3:
Question 1 of 10
The nurse is caring for a patient who underwent kidney transplantation 8 hours ago. Which finding
would indicate that the patient is developing hyperacute rejection?
Pale and yellow urine
, Decreased to no urine output
Increased white blood cell count
Maculopapular palmar skin lesions ✔Correct Answer-Decreased to no urine output
Hyperacute rejection usually occurs within the first 24 hours after transplantation. The first sign is
that the transplanted organ stops working. Because this patient received a kidney, this would be
evidenced by a decrease in or absence of urinary output.
Question 2 of 10
Which patient would the nurse expect to be at highest risk for developing graft-versus-host disease
(GVHD)?
Patient who had a lung transplant 4 years ago
Patient who is taking immunosuppressant drugs
Patient who had a recent bone marrow transplant
Patient who had a negative result for crossmatching ✔Correct Answer-Patient who had a recent
bone marrow transplant
A patient who has undergone bone marrow or stem cell transplantation is at the highest risk of
developing GVHD.
Question 3 of 10
A patient who underwent organ transplantation 2 months ago is admitted to the hospital with acute
rejection. Which order would the nurse anticipate from the health care provider?
Administration of intravenous antibiotics
Increased doses of monoclonal antibodies
Surgery to remove the transplanted organ
A decrease in the daily dose of corticosteroids ✔Correct Answer-Increased doses of monoclonal
antibodies
The treatment for acute rejection is administration of increased doses of monoclonal antibodies.
Question 4 of 10
A female transplant recipient asks the nurse to explain why she is receiving a cytotoxic drug even
though she does not have cancer. What is the nurse's best response?
"I will recheck the health care provider's prescription to determine whether this is a mistake."
"The use of chemotherapy medications can play an important role in preventing organ rejection."
"Immunosuppressant medications can place you at risk for cancer, and this drug will prevent it."
"Have you been diagnosed with cancer in the past? This may be why this medication has been
prescribed." ✔Correct Answer-"The use of chemotherapy medications can play an important role
in preventing organ rejection."
Cyclophosphamide is a cytotoxic drug used to treat cancer, but it is also used to suppress the
immune system.
Question 5 of 10
What will the nurse include in the discharge teaching for a patient who has received a prescription
for prednisone after liver transplantation?
Select all that apply.
"Weigh yourself daily."
"Take daily calcium supplements."
"Do not suddenly stop taking the drug."
"Take prednisone on an empty stomach."
"Drink 2000 to 3000 mL of water every day." ✔Correct Answer-Weigh yourself daily."
Corticosteroids cause water retention and increased appetite. Therefore the nurse would instruct the
patient to weigh himself or herself every day.
Answers |Actual Complete Exam| Already Graded A+
(Just Released)
Overview of Burn Injuries:
A nurse is caring for a patient who spilled boiling soup on her legs. Which type of burn will the nurse
see?
Thermal
Electrical
Chemical
Smoke inhalation ✔Correct Answer-Thermal
Thermal burns are caused by flame, flash, scald, or contact with hot objects (such as boiling soup).
Question 2 of 6
A family member of a patient with a severe facial burn asks the nurse why the patient's face is
swollen. Which statement made by the nurse is appropriate?
"Swelling is an expected inflammatory response of the body to a burn injury."
"Swelling occurs when a person is allergic to the substance that caused the burn."
"Moderate swelling is an expected side effect of the pain medications we are giving."
"Some swelling is expected during treatment because the patient has been lying down and resting."
✔Correct Answer-"Swelling is an expected inflammatory response of the body to a burn injury."
Swelling is expected after a burn injury because of increased capillary permeability, which results in
leakage of fluids and electrolytes into the interstitium.
Question 3 of 6
A student nurse is caring for a patient with severe thermal burns. Which statement made by the
student nurse to the charge nurse indicates that additional teaching is needed?
"I will assess my patient regularly for pain and anxiety."
"An inflammatory response is necessary for the body to begin the healing process."
"The severity of my patient's burns is a result of the temperature of the burning agent and the
contact time."
"I will check my patient hourly to make sure that he does not experience an inflammatory response
from his burns." ✔Correct Answer-"I will check my patient hourly to make sure that he does not
experience an inflammatory response from his burns."
An inflammatory response is expected after a burn injury and is necessary for the healing process to
begin. The nursing student needs additional teaching about the role of an inflammatory response in
the healing process.
Question 4 of 6
A nurse is caring for a patient with a first-degree thermal burn injury. Which symptom can the nurse
expect to see on assessment?
Insensitivity to pain
Cherry-red skin color
Blanching with pressure
Edema of surrounding tissue ✔Correct Answer-Blanching with pressure
Blanching with pressure is an expected clinical manifestation of a partial-thickness superficial (first-
degree) thermal burn injury.
,Question 5 of 6
What is the proper classification for a thermal burn involving only the epidermis and superficial
structures of the dermis?
Superficial burn
Deep tissue burn
Full-thickness burn
Partial-thickness burn ✔Correct Answer-Partial-thickness burn
A partial-thickness burn involves the epidermis and the superficial structures of the dermis.
Question 6 of 6
When calculating the total body surface area (TBSA) affected by a burn, the nurse knows that the
Lund-Browder chart is considered more accurate than the rule of nines for which reason?
The rule of nines does not include burns to the chest in calculation of TBSA.
The Lund-Browder chart considers the age of the patient in calculation of TBSA.
The rule of nines does not consider the size of the patient in calculation of TBSA.
The Lund-Browder chart considers the weight of the patient in calculation of TBSA. ✔Correct
Answer-The Lund-Browder chart considers the age of the patient in calculation of TBSA.
The Lund-Browder chart considers the age of the patient in calculation of TBSA. The rule of nines
does not consider the age of the patient in the calculation.
Collaborative Care and Nursing Management of Burn Injuries:
Question 1 of 6
A nurse is caring for a newly admitted patient in the emergent phase after a severe electrical burn.
Which provider orders should the nurse question?
Obtain an ECG in 8 hours
Administer PO pain medication
Insert large-bore IV to provide fluids
Contact anesthesiologist to begin intubation ✔Correct Answer-Obtain an ECG in 8 hours
The patient should have an ECG performed now, not delayed for 8 hours. The patient with an
electrical burn injury is at risk for cardiac dysrhythmias. The nurse should question this provider
order.
Administer PO pain medication
Patients in the emergent phase of burn management should be treated for pain, but PO is not an
appropriate management technique because pain medications will be administered intravenously.
The nurse should question this provider order.
Question 2 of 6
A nurse is caring for a patient with a chemical burn to the left extremity who is in the rehabilitative
phase of burn management. Which order would the nurse anticipate from the health care provider?
Begin IV pain medications
Provide patient education on wound care
Continue a low-calorie diet to support wound healing
Provide information on obtaining home oxygen services ✔Correct Answer-Provide patient
education on wound care
The rehabilitation phase begins when the patient's wounds are healed and he or she is engaging in
some form of self-care. It is appropriate to provide the patient with education on wound care during
this phase.
Question 3 of 6
What is the total 24-hour fluid requirement in milliliters for a 55-kg adult patient with 75% TBSA
burned? ✔Correct Answer-16500
,4 mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface
area (% TBSA) burned = Total fluid requirements for first 24 hours after burn
4 mL × 55 kg × 75 = 16500 mL
Question 4 of 6
The nurse is caring for a patient who was just transported by EMS to the hospital for burns to the
legs, chest, arms, and face. Which nursing interventions are appropriate at this time?
Select all that apply.
Prepare to initiate tube feeding as indicated
Insert urinary catheter to monitor intake and output
Administer oral analgesic of acetaminophen 650 mg
Discuss home care and rehabilitation with the patient's family
Monitor oxygen status and provide supplemental oxygen as needed ✔Correct Answer-Insert
urinary catheter to monitor intake and output
The nurse is caring for a patient in the emergent phase of burn management. It is appropriate to
insert a catheter to monitor the intake and output during this phase to effectively assess fluid status.
Monitor oxygen status and provide supplemental oxygen as needed
The nurse is assessing a patient in the emergent phase of burn management. It is appropriate to
monitor oxygen and provide supplemental oxygen as needed because the patient may be at risk for
impaired perfusion and ventilation.
Question 5 of 6
A patient is admitted to the burn center with burns to the neck and chest after a gasoline explosion
at work. Emergency transport reported wheezing in the upper lung fields. Upon initial assessment,
the nurse notes no current wheezing and diminished breath sounds throughout. What is the
appropriate action for the nurse to take?
Check vital signs and obtain arterial blood gas values.
Sit the patient upright and encourage deep breathing.
Contact the health care provider and prepare for emergency intubation.
Continue with the assessment, observing for edema and cardiac output. ✔Correct Answer-Contact
the health care provider and prepare for emergency intubation.
The patient is likely to have inhalation burn injuries, and intubation is necessary to maintain
oxygenation and ventilation.
Question 6 of 6
A patient with facial burns frequently asks the nurse, "When will I look normal again?" Which is an
appropriate response by the nurse?
"You seem to be very anxious. Would you like to talk about how you're feeling?"
"It's okay to be afraid of how your face looks now, but it will get better with time."
"I noticed that you've been asking this question often. Are you feeling depressed?"
"You will likely need to have some reconstructive treatment before seeing an improvement."
✔Correct Answer-"You seem to be very anxious. Would you like to talk about how you're feeling?"
The patient is verbally expressing signs of anxiety. The nurse should attend to the patient's
psychologic and emotional needs at this time.
Transplantation-Week 3:
Question 1 of 10
The nurse is caring for a patient who underwent kidney transplantation 8 hours ago. Which finding
would indicate that the patient is developing hyperacute rejection?
Pale and yellow urine
, Decreased to no urine output
Increased white blood cell count
Maculopapular palmar skin lesions ✔Correct Answer-Decreased to no urine output
Hyperacute rejection usually occurs within the first 24 hours after transplantation. The first sign is
that the transplanted organ stops working. Because this patient received a kidney, this would be
evidenced by a decrease in or absence of urinary output.
Question 2 of 10
Which patient would the nurse expect to be at highest risk for developing graft-versus-host disease
(GVHD)?
Patient who had a lung transplant 4 years ago
Patient who is taking immunosuppressant drugs
Patient who had a recent bone marrow transplant
Patient who had a negative result for crossmatching ✔Correct Answer-Patient who had a recent
bone marrow transplant
A patient who has undergone bone marrow or stem cell transplantation is at the highest risk of
developing GVHD.
Question 3 of 10
A patient who underwent organ transplantation 2 months ago is admitted to the hospital with acute
rejection. Which order would the nurse anticipate from the health care provider?
Administration of intravenous antibiotics
Increased doses of monoclonal antibodies
Surgery to remove the transplanted organ
A decrease in the daily dose of corticosteroids ✔Correct Answer-Increased doses of monoclonal
antibodies
The treatment for acute rejection is administration of increased doses of monoclonal antibodies.
Question 4 of 10
A female transplant recipient asks the nurse to explain why she is receiving a cytotoxic drug even
though she does not have cancer. What is the nurse's best response?
"I will recheck the health care provider's prescription to determine whether this is a mistake."
"The use of chemotherapy medications can play an important role in preventing organ rejection."
"Immunosuppressant medications can place you at risk for cancer, and this drug will prevent it."
"Have you been diagnosed with cancer in the past? This may be why this medication has been
prescribed." ✔Correct Answer-"The use of chemotherapy medications can play an important role
in preventing organ rejection."
Cyclophosphamide is a cytotoxic drug used to treat cancer, but it is also used to suppress the
immune system.
Question 5 of 10
What will the nurse include in the discharge teaching for a patient who has received a prescription
for prednisone after liver transplantation?
Select all that apply.
"Weigh yourself daily."
"Take daily calcium supplements."
"Do not suddenly stop taking the drug."
"Take prednisone on an empty stomach."
"Drink 2000 to 3000 mL of water every day." ✔Correct Answer-Weigh yourself daily."
Corticosteroids cause water retention and increased appetite. Therefore the nurse would instruct the
patient to weigh himself or herself every day.
