Chapter 25: Nursing Management: Burns My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 25: Nursing Management: 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 red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as

a.

full-thickness skin destruction.

b.

deep full-thickness skin destruction.

c.

deep partial-thickness skin destruction.

d.

superficial partial-thickness skin destruction.

ANS: C

The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present.

DIF: Cognitive Level: Comprehension REF: 475

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 56%, Hb 17.2 mg/dL (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking?

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 patients record.

ANS: B

The patients lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.

DIF: Cognitive Level: Application REF: 479-483 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

3. A patient is admitted to the burn unit with 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. 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 immediately be notified so that intubation can rapidly be done. 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: Application REF: 481-482

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, the nurse will decrease the fluid infusion rate to

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: Application REF: 483

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

a.

Check skin turgor.

b.

Monitor daily weight.

c.

Assess mucous membranes.

d.

Measure hourly urine output.

ANS: D

When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patients weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

DIF: Cognitive Level: Application REF: 483 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

6. To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to

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.

ANS: A

Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patients caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

DIF: Cognitive Level: Application REF: 486 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

7. A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will 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 patient.

c.

Turn the room temperature up to at least 68 F (20 C) during dressing changes.

d.

Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

ANS: B

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 85 F for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

DIF: Cognitive Level: Application REF: 483-485 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

8. Which action will be included in the plan of care for a patient 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 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.

ANS: B

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.

DIF: Cognitive Level: Application REF: 485

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action 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 patient to flex and extend the fingers.

ANS: A

The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the patients circulation.

DIF: Cognitive Level: Application REF: 480

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. Ranitidine (Zantac) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication?

a.

Bowel sounds

b.

Stool frequency

c.

Abdominal distention

d.

Stools for occult blood

ANS: D

H2 blockers are given to prevent Curlings ulcer in the patient who has suffered burn injuries. H2 blockers do not impact on bowel sounds, stool frequency, or appetite.

DIF: Cognitive Level: Application REF: 487-488 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

11. Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement?

a.

ketorolac (Toradol)

b.

lorazepam (Ativan)

c.

gabapentin (Neurontin)

d.

hydromorphone (Dilaudid)

ANS: D

Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.

DIF: Cognitive Level: Application REF: 485

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which action by the patient 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.

ANS: C

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

DIF: Cognitive Level: Application REF: 492 TOP: Nursing Process: Evaluation

MSC: NCLEX: Psychosocial Integrity

13. The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when

a.

white blood cell levels decrease.

b.

blisters and edema have subsided.

c.

the patient has large quantities of pale urine.

d.

the patient has been hospitalized for 48 hours.

ANS: C

At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patients immune status and any infectious processes.

DIF: Cognitive Level: Comprehension REF: 479-480

TOP: Nursing Process: Application MSC: NCLEX: Physiological Integrity

14. Which of these snacks will be best for the nurse to offer to a patient 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

ANS: D

A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.

DIF: Cognitive Level: Application REF: 486 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

15. What is the priority nursing assessment when caring for a patient 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

ANS: C

All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status.

DIF: Cognitive Level: Application REF: 474

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

16. After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take?

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.

ANS: D

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

DIF: Cognitive Level: Application REF: 477

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

17. A patient who has burns on the back and chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first?

a.

Stay at the bedside and reassure the patient.

b.

Administer the ordered morphine sulfate IV.

c.

Assess orientation and level of consciousness.

d.

Use pulse oximetry to check the oxygen saturation.

ANS: D

Agitation in a patient who may have suffered inhalation injury might indicate hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

DIF: Cognitive Level: Application REF: 481

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

18. Which of these actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire?

a.

Infuse the ordered IV solution.

b.

Auscultate the patients lung sounds.

c.

Determine the extent and depth of the burns.

d.

Administer the ordered opioid pain medications.

ANS: B

A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

DIF: Cognitive Level: Application REF: 487

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

19. A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these 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.

ANS: B

After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.

DIF: Cognitive Level: Application REF: 474 | 478

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

20. Six hours after a thermal burn covering 50% of a patients total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information 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 per hour for the past 2 hours.

ANS: D

The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

DIF: Cognitive Level: Application REF: 478-483

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

21. After receiving change-of-shift report, which of these patients should the nurse assess first?

a.

A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

b.

A patient with smoke inhalation who has wheezes and altered mental status

c.

A patient with full-thickness leg burns who has a dressing change scheduled

d.

A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

ANS: B

This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

DIF: Cognitive Level: Application REF: 481

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

22. Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit?

a.

A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

b.

A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest

c.

A 60-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

d.

A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)

ANS: D

An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

DIF: Cognitive Level: Analysis REF: 488-490

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

23. The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first?

a.

Insert two large-bore IV lines.

b.

Check the patients orientation.

c.

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

d.

Assess for singed nasal hair and dark oral mucous membranes.

ANS: C

The patients history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.

DIF: Cognitive Level: Application REF: 474 | 481

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

24. Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?

a.

Hct 52%

b.

BUN 36 mg/dL

c.

Serum sodium 146 mEq/L

d.

Serum potassium 6.2 mEq/L

ANS: D

Hyperkalemia can lead to fatal bradycardia and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values also are abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

DIF: Cognitive Level: Application REF: 487

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

25. The RN observes all of the following actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?

a.

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

b.

The float nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C).

c.

The float nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.

d.

The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.

ANS: A

Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

DIF: Cognitive Level: Application REF: 484

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

26. Which of these nursing actions should be done first for a patient 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.

ANS: B

Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions also are included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

DIF: Cognitive Level: Application REF: 474 | 478

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula, calculate the volume of lactated Ringers solution that the nursing staff will administer during the first 24 hours.

__________________

ANS:

8400 mL

The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours.

DIF: Cognitive Level: Application REF: 483

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patients total body surface area (TBSA) has been injured?

__________________

ANS:

27%

When using the rule of nines, the posterior trunk is considered to cover 18% of the patients body and each arm is 9%.

DIF: Cognitive Level: Comprehension REF: 476

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patients back? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

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.

ANS:

D, E, C, A, B

Since partial-thickness burns are very painful, the nurses 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.

DIF: Cognitive Level: Application REF: 488 | 490

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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