chapter 27

Question 1

The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that the skin is red, swollen, and covered with large blisters. The client states that they are very painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destruction
b. Deep full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction

Answer 1

c. Deep partial-thickness skin destruction

Question 2

The nurse is admitting a client to the burn unit who has an approximate 25% total body surface area (TBSA) burn and the following initial laboratory results: Hct 56%, Hb 172 g/L, serum K+ 4.8 mmol/L, and serum Na+ 135 mmol/L. Which of the following actions
should the nurse anticipate implementing?
a. Continue to monitor the laboratory results.
b. Increase the rate of the ordered IV solution.
c. Type and crossmatch for a blood transfusion.
d. Document the findings in the client’s record.

Answer 2

b. Increase the rate of the ordered IV solution.

Question 3

The nurse is admitting a client to the burn unit who has burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. Which of the following actions should the nurse
implement first?
a. Encourage the client 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 client’s respiratory rate.
d. Reposition the client in high-Fowler’s position and reassess breath sounds.

Answer 3

b. Notify the health care provider and prepare for endotracheal intubation.

Question 4

The nurse is caring for a client with severe burns who is receiving crystalloid fluid replacement IV, 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 1 875 mL/hour. Which of the following infusion rates is accurate after the first 8 hours?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1 250 mL/hour

Answer 4

c. 938 mL/hour

Question 5

The nurse is caring for a client who is in the emergent phase of burn care. Which of the following nursing actions will be most useful in determining whether the client is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.

Answer 5

d. Measure hourly urine output.

Question 6

The nurse is caring for a client who has just been admitted with a 40% total body surface area (TBSA) burn injury. Which of the following interventions should the nurse include in the plan of care to maintain adequate nutrition?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5 000 kcal/day.
d. Administer multiple vitamins and minerals in the IV solution.

Answer 6

a. Insert a feeding tube and initiate enteral feedings.

Question 7

The nurse is caring for a client who has deep partial-thickness and full-thickness burns of the face and chest and is having the wounds treated with the open method. Which of the following nursing actions should be included in the plan of care?
a. Restrict all visitors to prevent cross-contamination of wounds.
b. Wear gowns, caps, masks, and gloves during all care of the client.
c. Turn the room temperature up to at least 20°C (68°F) during dressing changes.
d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

Answer 7

b. Wear gowns, caps, masks, and gloves during all care of the client.

Question 8

Which of the following actions should be included in the plan of care for a client who has burns of the ears, head, neck, and right arm and hand?
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 client to a supine position with a small pillow under the head.
d. Position the client in a side-lying position with rolled towel under the neck.

Answer 8

b. Elevate the right arm and hand on pillows and extend the fingers.

Question 9

The nurse is caring for a client who has circumferential burns of both arms and develops a decrease in radial pulse strength and numbness in the fingers. Which of the following actions should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both arms above heart level with pillows.
d. Encourage the client to flex and extend the fingers.

Answer 9

a. Notify the health care provider.

Question 10

The nurse is caring for a client who incurred extensive burn injuries 5 days ago and has been prescribed ranitidine. Which of the following assessments should the nurse use to evaluate the effectiveness of the medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood

Answer 10

d. Stools for occult blood

Question 11

The nurse is caring for a client who has partial-thickness burns. Which of the following prescribed medications will be best for the nurse to use before wound debridement?
a. Ketorolac
b. Lorazepam
c. Gabapentin
d. Hydromorphone

Answer 11

d. Hydromorphone

Question 12

The nurse is caring for a client who is in the rehabilitation phase after having deep partial-thickness face and neck burns and has a nursing diagnosis of disturbed body image. Which of the following actions by the client indicates that the problem is resolving?
a. Stating that the scarring will only be temporary
b. Avoiding using a pillow to prevent neck contractures
c. Asking about how to use make-up to cover up the scars
d. Expressing sadness and anger about the scar appearance

Answer 12

c. Asking about how to use make-up to cover up the scars

Question 13

The nurse is caring for a client who has burns over 30% of the body surface. Which of the following events indicates that the client has moved from the emergent to the acute phase of the burn injury?
a. White blood cell levels decrease.
b. Blisters and edema have subsided.
c. The client has large quantities of pale urine.
d. The client has been hospitalized for 48 hours.

Answer 13

c. The client has large quantities of pale urine.

Question 14

Which of the following snacks will be best for the nurse to offer to a client with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn
treatment?
a. Strawberry gelatin
b. Whole wheat bagel
c. Chunky applesauce
d. Chocolate milkshake

Answer 14

d. Chocolate milkshake

Question 15

Which of the following assessment parameters is the priority nursing assessment when caring for a client who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light

Answer 15

c. Extremity movement

Question 16

The occupational health nurse is assessing an employee who has just spilled industrial acids on the arms and legs. Which of the following actions is priority for the nurse to implement?
a. Apply an alkaline solution to the affected area.
b. Place cool compresses on the area of exposure.
c. Cover the affected area with dry, sterile dressings.
d. Flush the burned area with large amounts of water.

Answer 16

d. Flush the burned area with large amounts of water.

Question 17

The nurse is caring for a client who has burns on the back and chest from a house fire and has become agitated and restless 9 hours after being admitted to the hospital. Which of the following actions should the nurse take first?
a. Stay at the bedside and reassure the client.
b. Administer the ordered morphine sulphate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.

Answer 17

d. Use pulse oximetry to check the oxygen saturation.

Question 18

Which of the following actions should the nurse take first when a client arrives in the emergency department with facial and chest burns caused by a house fire?
a. Infuse the ordered IV solution.
b. Auscultate the client’s lung sounds.
c. Determine the extent and depth of the burns.
d. Administer the ordered opioid pain medications.

Answer 18

b. Auscultate the client’s lung sounds.

Question 19

The nurse is admitting a client with extensive electrical burn injuries. Which of the following prescribed interventions should the nurse implement first?
a. Start two large bore IVs.
b. Place on cardiac monitor.
c. Apply dressings to burned areas.
d. Assess for pain at contact points.

Answer 19

b. Place on cardiac monitor.

Question 20

Six hours after a thermal burn covering 50% of a client’s total body surface area (TBSA), the nurse obtains these data when assessing a client. Which of the following information is priority for the nurse to communicate to the health care provider?
a. Blood pressure is 94/46 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 104.
d. Urine output is 20 mL/hour for the past 2 hours.

Answer 20

d. Urine output is 20 mL/hour for the past 2 hours.

Question 21

After receiving change-of-shift report, which of the following clients should the nurse assess first?
a. A client with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
b. A client with smoke inhalation who has wheezes and altered mental status
c. A client with full-thickness leg burns who has a dressing change scheduled
d. A client with abdominal burns who is complaining of level 8 (0–10 scale) pain

Answer 21

b. A client with smoke inhalation who has wheezes and altered mental status

Question 22

Which of the following frequencies of multiple-dressing method burn treatment dressing changes should the nurse should question?
a. Every 6 hours
b. Every 12 hours
c. Once a day
d. Once a week

Answer 22

a. Every 6 hours

Question 23

The nurse notes a bright red skin colour for a client who was found unconscious from smoke inhalation in a burning house. Which of the following actions should the nurse take first?
a. Insert two large-bore IV lines.
b. Check the client’s orientation.
c. Place the client on 100% oxygen using a non-rebreather mask.
d. Assess for singed nasal hair and dark oral mucous membranes.

Answer 23

c. Place the client on 100% oxygen using a non-rebreather mask.

Question 24

Which of the following laboratory results requires the most rapid action by the nurse who is caring for a client who suffered a large burn 48 hours ago?
a. Hct 52%
b. BUN 13.8 mmol/L
c. Serum sodium 146 mmol/L
d. Serum potassium 6.2 mmol/L

Answer 24

d. Serum potassium 6.2 mmol/L

Question 25

The staff nurse is supervising a student nurse on the burn unit. Which of the following actions by the student nurse require that the staff nurse intervene?
a. The student nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
b. The student nurse obtains burn cultures when the client has a temperature of 35.1°C (95.1°F).
c. The student nurse administers PRN fentanyl IV to a client 5 minutes before a dressing change.
d. The student nurse calls the health care provider for an insulin order when a nondiabetic client has an elevated serum glucose.

Answer 25

a. The student nurse uses clean latex gloves when applying antibacterial cream to a burn wound.

Question 26

Which of the following nursing actions should be done first for a client who has suffered a burn injury while working on an electrical power line?
a. Obtain the blood pressure.
b. Stabilize the cervical spine.
c. Assess for the contact points.
d. Check alertness and orientation.

Answer 26

b. Stabilize the cervical spine.