Question 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?

Accepted Answer

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

Question 2

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm.What percentage of the patient's total body surface area (TBSA)has been injured?

Accepted Answer

27%
When using the rule of nines,the anterior trunk is considered to cover 18% of the patient's body and each arm is 9%.

Question 3

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. B

Question 4

A nurse is caring for a patient who has burns of the ears,head,neck,and right arm and hand.The nurse should place the patient in which position?

Accepted Answer

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 patient to a supine position with a small pillow under the head.
D)   Position the patient in a side-lying position with rolled towel under the neck.

Question 5

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 6

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current.What is the priority nursing assessment?

Accepted Answer

A)   Oral temperature
B)   Peripheral pulses
C)   Extremity movement
D)   Pupil reaction to light

Question 7

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago.Which result requires priority action by the nurse?

Accepted Answer

A)   Hematocrit 53%
B)   Serum sodium 147 mEq/L
C)   Serum potassium 6.1 mEq/L
D)   Blood urea nitrogen 37 mg/dL

Question 8

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 9

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 10

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 11

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?

Accepted Answer

A)   350 mL/hour
B)   523 mL/hour
C)   938 mL/hour
D)   1250 mL/hour

Question 12

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 13

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.

Question 14

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 15

A patient has just been admitted with a 40% total body surface area (TBSA)burn injury.To maintain adequate nutrition,the nurse should plan to take which action?

Accepted Answer

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 5000 kcal per day.
D)   Administer multiple vitamins and minerals in the IV solution.

Question 16

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 17

A patient with burns covering 40% total body surface area (TBSA)is in the acute phase of burn treatment.Which snack would be best for the nurse to offer to this patient?

Accepted Answer

A)   Bananas
B)   Orange gelatin
C)   Vanilla milkshake
D)   Whole grain bagel

Question 18

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 19

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].)

Accepted Answer

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.

Question 20

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)

Exam 21: Nursing Management: Burns