Question 1

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A,B,C,D,E].)
A) Apply sterile gauze dressing.
B) Document wound appearance.
C) Apply silver sulfadiazine cream.
D) Administer IV fentanyl (Sublimaze).
E) Clean wound with saline-soaked gauze.

Accepted Answer

D,E,C,A,B
Because partial-thickness burns are very painful,the nurse's first action should be to administer pain medications.The wound will then be cleaned,antibacterial cream applied,and covered with a new sterile dressing.The last action should be to document the appearance of the wound.

Question 2

A patient with extensive electrical burn injuries is admitted to the emergency department.Which prescribed intervention should the nurse implement first?

Accepted Answer

A)   Assess oral temperature.
B)   Check a potassium level.
C)   Place on cardiac monitor.
D)   Assess for pain at contact points. C

Question 3

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Accepted Answer

A)   Obtain the blood pressure.
B)   Stabilize the cervical spine.
C)   Assess for the contact points.
D)   Check alertness and orientation. B

Question 4

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?

Accepted Answer

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.

Question 5

While the patient's full-thickness burn wounds to the face are exposed,what is the best nursing action to prevent cross contamination?

Accepted Answer

A)   Use sterile gloves when removing old dressings.
B)   Wear gowns, caps, masks, and gloves during all care of the patient.
C)   Administer IV antibiotics to prevent bacterial colonization of wounds.
D)   Turn the room temperature up to at least 70° F (20° 
C)   during dressing changes.

Question 6

The nurse is reviewing the medication administration record (MAR)on a patient with partial-thickness burns.Which medication is best for the nurse to administer before scheduled wound debridement?

Accepted Answer

A)   Ketorolac (Toradol) 
B)   Lorazepam (Ativan) 
C)   Gabapentin (Neurontin) 
D)   Hydromorphone (Dilaudid)

Question 7

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

Accepted Answer

A)   Keep the right arm in a position of comfort.
B)   Avoid the use of sustained-release narcotics.
C)   Teach about the purpose of tetanus immunization.
D)   Apply water-based cream to burned areas frequently.

Question 8

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA)the nurse assesses the patient.Which information would be a priority to communicate to the health care provider?

Accepted Answer

A)   Blood pressure is 95/48 per arterial line.
B)   Serous exudate is leaking from the burns.
C)   Cardiac monitor shows a pulse rate of 108.
D)   Urine output is 20 mL per hour for the past 2 hours.

Question 9

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance.The nurse notes that the patient's skin color is bright red.Which action should the nurse take first?

Accepted Answer

A)   Insert two large-bore IV lines.
B)   Check the patient's orientation.
C)   Assess for singed nasal hair and dark oral mucous membranes.
D)   Place the patient on 100% oxygen using a non-rebreather mask.

Question 10

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?

Accepted Answer

A)   First-degree skin destruction
B)   Full-thickness skin destruction
C)   Deep partial-thickness skin destruction
D)   Superficial partial-thickness skin destruction

Question 11

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes.Which action should the nurse take?

Accepted Answer

A)   Notify the health care provider.
B)   Monitor the pulses every 2 hours.
C)   Elevate both legs above heart level with pillows.
D)   Encourage the patient to flex and extend the toes on both feet.

Question 12

Esomeprazole (Nexium)is prescribed for a patient who incurred extensive burn injuries 5 days ago.Which nursing assessment would best evaluate the effectiveness of the medication?

Accepted Answer

A)   Bowel sounds
B)   Stool frequency
C)   Abdominal distention
D)   Stools for occult blood

Question 13

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN)who has floated from the hospital medical unit?

Accepted Answer

A)   A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings.
B)   A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration
C)   A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest
D)   A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

Question 14

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?

Accepted Answer

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 patient's respiratory rate.
D)   Reposition the patient in high-Fowler's position and reassess breath sounds.

Question 15

The charge nurse observes the following actions being taken by a new nurse on the burn unit.Which action by the new nurse would require an intervention by the charge nurse?

Accepted Answer

A)   The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
B)   The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° 
C)  .
C)   The new nurse administers PRN fentanyl (Sublimaze)  IV to a patient 5 minutes before a dressing change.
D)   The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

Question 16

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased.Which action by the nurse would best ensure adequate kidney function?

Accepted Answer

A)   Continue to monitor the urine output.
B)   Monitor for increased white blood cells (WBCs) .
C)   Assess that blisters and edema have subsided.
D)   Prepare the patient for discharge from the burn unit.

Question 17

During the emergent phase of burn care,which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Accepted Answer

A)   Check skin turgor.
B)   Monitor daily weight.
C)   Assess mucous membranes.
D)   Measure hourly urine output.

Question 18

A patient arrives in the emergency department with facial and chest burns caused by a house fire.Which action should the nurse take first?

Accepted Answer

A)   Auscultate the patient's lung sounds.
B)   Determine the extent and depth of the burns.
C)   Infuse the ordered lactated Ringer's solution.
D)   Administer the ordered hydromorphone (Dilaudid) .

Question 19

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse,"I'm sorry that I'm still alive.My life will never be normal again." Which response by the nurse is best?

Accepted Answer

A)   "Most people recover after a burn and feel satisfied with their lives."
B)   "It's true that your life may be different. What concerns you the most?"
C)   "It is really too early to know how much your life will be changed by the burn."
D)   "Why do you feel that way? You will be able to adapt as your recovery progresses."

Question 20

An employee spills industrial acids on both arms and legs at work.What is the priority action that the occupational health nurse at the facility should take?

Accepted Answer

A)   Remove nonadherent clothing and watch.
B)   Apply an alkaline solution to the affected area.
C)   Place cool compresses on the area of exposure.
D)   Cover the affected area with dry, sterile dressings.

Exam 25: Nursing Management: Burns