Chapter 35 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 35

Question 1

Type: MCSA

Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries?

1. 25-year-old pregnant female

2. 49-year-old male who smokes

3. 75-year-old female with arthritis

4. 50-year-old male with coronary artery disease

Correct Answer: 3

Rationale 1: Pregnancy is not a factor in increasing mortality from burn injury.

Rationale 2: This patient does not have the greatest risk of mortality from this burn injury.

Rationale 3: People of advancing age have thinner skin, with decreased microcirculation and an increased susceptibility to infection. All of these factors not only put them at a greater risk for burn injuries, but also lead to a greater morbidity and mortality.

Rationale 4: Coronary artery disease does not make this patient at higher risk than another patient also injured in this fire.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-1

Question 2

Type: MCSA

The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication?

1. Pain

2. Burn shock

3. Continuation of the burn process below the level of obvious injury

4. Hypervolemia

Correct Answer: 2

Rationale 1: Thermal burns are painful, but this is not the most serious complication listed.

Rationale 2: Thermal burns produce microvascular and inflammatory responses within minutes of the injury; however, the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state, which is frequently referred to as burn shock.

Rationale 3: Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn not a thermal burn.

Rationale 4: It would be more likely that the patient would develop hypovolemia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-1

Question 3

Type: MCSA

A civilian patient admitted with frostbite burns to his feet is receiving pain medication, fluid replacement, and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management?

1. Frostbite injuries are not as serious as thermal or chemical burns.

2. The extent of the injury is not obvious.

3. Little is known about other methods to treat frostbite.

4. Aggressive frostbite management is only done in specialty military hospitals.

Correct Answer: 2

Rationale 1: Frostbite injuries can be devastating.

Rationale 2: Since it may take weeks before there is a clear demarcation between viable and nonviable tissue with frostbite injuries, patients are treated conservatively, which includes fluid support, pain management, and ongoing assessment of organ functioning.

Rationale 3: This treatment approach is not related to lack of knowledge of other potential treatments.

Rationale 4: Hospitals of all descriptions generally approach frostbite care conservatively.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-1

Question 4

Type: MCMA

A patient is being admitted for treatment of deep partial-thickness burns. When doing this patients initial assessment, the nurse would expect which burn characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sluggish capillary refill

2. Leathery, white tissue

3. Significant edema

4. Blisters

5. Erythema

Correct Answer: 1,3,5

Rationale 1: The deep partial-thickness burn damages capillaries. Capillary refill may be sluggish or absent.

Rationale 2: Leathery, white tissue is characteristic of full-thickness burns.

Rationale 3: Deep partial-thickness burns result in a significant amount of edema.

Rationale 4: No blisters are present in deep partial-thickness burns.

Rationale 5: Erythema can be present with these burns, or the tissues may be pale.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-2

Question 5

Type: MCSA

A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patients burn injuries?

1. Superficial

2. Deep partial thickness

3. Superficial partial thickness

4. Full thickness

Correct Answer: 1

Rationale 1: Superficial burns involve the epidermis only and are associated with burns from the sun. The burns are red and no blisters are present.

Rationale 2: Deep partial-thickness burns involve the epidermis and the deep layer of the dermis. They are caused by contact with flame, hot liquids, tar, or hot objects. Skin may be red or pale and capillary refill is sluggish or absent.

Rationale 3: Superficial partial-thickness burns involve the epidermis and papillary layer of the dermis and are caused by contact with hot objects, hot liquids, or flash flame. The skin is red with brisk capillary refill and blisters.

Rationale 4: Full-thickness burns involve the epidermis, dermis, and subcutaneous tissue. These are caused by contact with flame, electricity, or chemicals. The skin is dry and leathery or white with absent capillary refill.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-2

Question 6

Type: MCSA

A patient has full-thickness burns of the right chest area, entire right arm, and deep partial-thickness burns of both upper anterior legs. Based on the rule of nines, which estimate of total body surface area burn would the nurse record?

1. 36%

2. 27%

3. 45%

4. 18%

Correct Answer: 2

Rationale 1: This estimate is incorrect.

Rationale 2: According to the rules of nines, the right chest area = 9%, entire right arm = 9%, and the upper anterior legs = 4.5% + 4.5%. The total = 9 + 9 + 9 = 27%.

Rationale 3: This estimate is incorrect.

Rationale 4: This estimate is incorrect.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-2

Question 7

Type: MCMA

A patient is admitted with partial-thickness burns over the entire left arm and neck. Superficial burns are present on the face and scalp. The anterior truck has patches of superficial burns. There are deep partial-thickness burns on the legs with full-thickness burns on both feet. The nurse using the Lund and Browder chart to estimate the total body surface area burned will include the burns on which body areas?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Left arm

2. Face

3. Legs

4. Feet

5. Trunk

Correct Answer: 1,3,4

Rationale 1: Partial-thickness burns are included in this estimate.

Rationale 2: Superficial burns are not included in this estimate.

Rationale 3: Deep partial-thickness burns are included in this estimation.

Rationale 4: Full-thickness burns are included in this estimation.

Rationale 5: Superficial burns are not included in this estimation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-2

Question 8

Type: MCSA

The nurse is providing emergency care to patients injured in a house fire. Which patient would the nurse prepare for transfer to a burn center for additional care and treatment?

1. 15-year-old child with 5% total body surface area burns to the left arm

2. 10-year-old child with partial-thickness burns to the left hand

3. 30-year-old female with superficial burns to the arms, face, and neck

4. 35-year-old male with partial-thickness burn to a part of his back.

Correct Answer: 2

Rationale 1: The child with 5% total body surface burn to the left arm would not need to be transferred to the burn center since the total body surface area is less than 10%.

Rationale 2: The 10-year-old child would fulfill the burn center referral criteria for transfer to a burn center because the child has burns to the face and hands.

Rationale 3: Superficial burns can typically be addressed in a non-burn unit environment.

Rationale 4: Referral is considered when a partial-thickness burn occurs to more than 10% of TBSA.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-2

Question 9

Type: MCSA

The nurse is caring for a 154-pound patient with 50 percent total body surface area burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care?

1. 14,000 mL

2. 42,000 mL

3. 3,500 mL

4. 7,000 mL

Correct Answer: 1

Rationale 1: Based on the Parkland formula, the total amount of fluids required in the first 24 hours = 4 mL of Ringers lactate TBSA of burns patients weight in kgs. For this patient, 4 mL 50 70 kg = 14,000 mL; 7, 000 mL should be given in the first 8 hours; 3,500 mL in the second 8 hours; and 3,500 mL in the last 8 hours.

Rationale 2: This is an inaccurate calculation based on this patients weight and TBSA.

Rationale 3: This patient will require 3,500 mL in the last 8-hour period of the next 24 hours, not for the entire 24 hours.

Rationale 4: This patient will require 7, 000 mL of fluid in the first 8 hours of the next 24 hours.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-1

Question 10

Type: MCSA

A patient, recovering from being struck by lightning 36 hours prior to admission, is demonstrating an acute onset of confusion and muscle weakness. Which rationale would the nurse provide for this assessment?

1. The patient has is suffering a stroke unrelated to the injury.

2. The patient likely has an electrolyte imbalance.

3. The patient has developed a seizure disorder from the injury.

4. The patient is having delayed onset of neurological symptoms, which are common after a lightning injury.

Correct Answer: 4

Rationale 1: There is not enough information for the nurse to determine that the patient is suffering a stroke.

Rationale 2: Without more information the nurse cannot attribute this finding to an electrolyte imbalance.

Rationale 3: This assessment does not support the diagnosis of a seizure disorder.

Rationale 4: Neurological effects are common with electrical and lightning injuries. The onset of clinical manifestations may be acute or delayed. Patients may experience confusion, exhibit a flat affect, lose the ability to concentrate, or have short-term memory problems. Seizures, headaches, peripheral nerve damage, and loss of muscle strength may also be observed.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-4

Question 11

Type: MCSA

A patient with severe deep partial-thickness burns is scheduled for hydrotherapy at 10:00 a.m. every day. The patient has an order for Percocet (oxycodone and acetaminophen) two tablets by mouth every 4 to 6 hours PRN for pain. When developing the nursing care plan, the nurse should include which nursing order?

1. Administer two tablets of Percocet at 11:00 a.m. every day right after hydrotherapy.

2. Administer two tablets of Percocet at 10:00 a.m. every day prior to hydrotherapy.

3. Administer two tablets of Percocet at 9:00 a.m. every day prior to hydrotherapy.

4. Administer two tablets of Percocet at 9:45 a.m. every day prior to hydrotherapy.

Correct Answer: 3

Rationale 1: Giving Percocet after the procedure may decrease its effectiveness because it is easier to control pain before it becomes severe.

Rationale 2: Administering pain medication at the beginning of a painful procedure will not effectively manage the pain from the treatment.

Rationale 3: The nurse should plan to administer the pain medication prior to a painful procedure. Because it takes about 45 to 60 minutes for an oral medication to be absorbed, the nurse should plan to give Percocet at 9:00 a.m. every day, one hour prior to hydrotherapy.

Rationale 4: More time is needed in order for the Percocet to be effective.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-7

Question 12

Type: MCSA

A patient, being treated for burns over 40% of the total body surface area, is experiencing a hypermetabolic state. The nurse anticipates the addition of which type of medication to help reduce muscle wasting and accelerate healing time?

1. Antibiotics

2. Cardiac glycosides

3. Insulin

4. Calcium channel blockers

Correct Answer: 3

Rationale 1: Antibiotics are not the primary choice for this therapeutic effect.

Rationale 2: Cardiac glycosides may be indicated for this patient, but are not the drug class of choice for this therapeutic effect.

Rationale 3: Administration of insulin in severely burned patients has been shown to improve muscle protein synthesis, accelerate healing time, attenuate loss of lean body mass and decrease the acute phase response.

Rationale 4: Calcium channel blockers are not the drug class of choice for this therapeutic effect.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-5

Question 13

Type: MCMA

The nurse assesses a burn patients urine to be reddish-brown in color. Which interventions would the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Interventions to raise the urine pH to an alkaline level

2. Discontinuing orders for sodium bicarbonate

3. Irrigating the patients bladder with a sodium bicarbonate solution

4. Management of intravenous fluids to achieve a urine output of 75 mL per hour

5. Monitor for hypocalcemia.

Correct Answer: 1,5

Rationale 1: If a patient has experienced muscle damage from exposure to an electrical current or a crush-type injury, the urine may be a red to reddish-brown color. This discoloration results from myoglobin in the urine. The solubility of myoglobin increases in an alkaline environment, so maintaining alkaline urine will increase the rate of myoglobin clearance.

Rationale 2: The nurse would anticipate adding sodium bicarbonate to this patients treatment plan.

Rationale 3: Irrigating the patients bladder with sodium bicarbonate will not raise the urine pH.

Rationale 4: Adequate urine output of 75 to 100 mL per hour will help to increase the rate of myoglobin clearance.

Rationale 5: Treatment of myoglobinuria may result in hypocalcemia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-5

Question 14

Type: MCSA

The nurse caring for a patient who sustained burns of 30% of the total body surface area seven days ago is assessing the status of the patients wounds. Which phase of wound healing would the nurse expect to be occurring?

1. Contraction

2. Inflammatory

3. Maturation

4. Proliferative

Correct Answer: 2

Rationale 1: Contraction is not a phase of wound healing

Rationale 2: The inflammatory phase lasts approximately 2 weeks.

Rationale 3: The maturation phase of wound healing can last 6 to 18 months or longer depending on the wound.

Rationale 4: The proliferative phase begins after about two weeks and may last up to 1 month.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-6

Question 15

Type: MCMA

A patient has been treated in the burn unit for 3 months. What characteristics of wound healing would the nurse evaluate as normal?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Organization of collagen layers

2. Reepithelialization

3. Revascularization

4. Strengthening of the scar

5. Keloid production

Correct Answer: 1,4

Rationale 1: The patient should be in the maturation stage of wound healing, which is characterized by the organization of collagen layers.

Rationale 2: Reepithelialization occurs in the proliferative stage. This stage should be completed.

Rationale 3: Revascularization occurs in the proliferative stage.

Rationale 4: Strengthening of the scar occurs during the maturation phase, which should be happening at this point after injury.

Rationale 5: Keloids may occur during this stage, but this is not a normal finding.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-6

Question 16

Type: MCSA

The nurse caring for a patient admitted for burns over his torso and upper arms has clothing adhered to the skin. Which nursing action is indicated?

1. Leave the clothing in place and flush the areas with cooled water

2. Flush the clothing with hydrogen peroxide to clean the skin underneath

3. Cover the areas with gauze

4. Apply a topical antiseptic over the clothing areas

Correct Answer: 1

Rationale 1: Clothing, jewelry, belts, or anything containing heat is removed from the patient however adhered clothing or tar is left in place and cooled with water because removing it will cause further damage to the skin.

Rationale 2: The nurse should not use hydrogen peroxide on this wound.

Rationale 3: Simply covering the areas with gauze is an insufficient intervention.

Rationale 4: Applying a topical antiseptic over the clothing is an insufficient intervention.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-6

Question 17

Type: MCMA

The nurse is planning the care of a patient who has burns to the face, neck, upper chest, and both upper arms. To prevent contracture development, the nurse should include which interventions in the patients plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use a bed cradle over the burned areas.

2. Have patient assume the position of comfort while sleeping.

3. Administer analgesics prior to physical therapy.

4. Instruct the patient to avoid using pillows under the head.

5. Get the patient out of bed as soon as medically feasible.

Correct Answer: 3,4,5

Rationale 1: Using bed cradles is effective in preventing infection and irritation of burn wounds, but it has no direct effect on preventing contractures.

Rationale 2: The position of comfort is most often flexion, which should be avoided at all times.

Rationale 3: Physical therapy can be painful for patients with burns. Reducing the pain can help the patient be more participative in therapy sessions.

Rationale 4: Using pillows under the head leads to hyperflexion of the neck and burned surfaces will be touching each other. This may lead to developing contractures of the neck.

Rationale 5: Getting the patient out of bed and using the joints is the best way to prevent development of contracture. Total body mobilization is also beneficial to cardiopulmonary functioning.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-7

Question 18

Type: MCSA

The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which intervention is most important to facilitate the success of the patients ambulation?

1. Transfer the patient to a chair before ambulating.

2. Apply compression wraps to the lower extremities before getting out of bed.

3. Be certain the patient is well-hydrated before ambulation.

4. Have the patient perform incentive spirometry.

Correct Answer: 2

Rationale 1: Transferring the patient to a chair before ambulating may or may not be necessary.

Rationale 2: It is important to apply compression wraps on lower extremities before getting the patient out of bed in order to prevent venous stasis. If extremities are not wrapped, the patient is at risk for capillary bed bleeding, which could cause autograft failure or delay donor-site healing. Venous pooling coupled with prolonged immobility also predisposes the patient to deep-vein thrombosis. Wrapping the extremities continues until all wounds are healed and pressure garments are applied.

Rationale 3: The patient should always be well-hydrated, but hydration status is not the most important aspect of preparing a patient for ambulation.

Rationale 4: Use of incentive spirometry may help prevent development of pneumonia, but is not necessary in preparation for ambulation.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-7

Question 19

Type: MCSA

A patient is rehabilitating after a severe burn 6 months ago that left her with scars across her chest and abdomen. She says, I dont care what people think, I am going to the beach in a bikini next week. What most important information should the nurse provide?

1. This may be difficult since you are still supposed to be wearing your compression garment.

2. You need to avoid sun exposure to your scars for at least one year.

3. You should prepare yourself for how others will react to your scars.

4. Remember that you are prone to getting too hot easily.

Correct Answer: 2

Rationale 1: The patient probably is still supposed to be wearing her compression garment, but this is not the most important consideration.

Rationale 2: Scars should be protected from sun exposure for one year or until the scar turns silvery white. Otherwise the scar will tan and remain permanently pigmented, leaving a less than satisfactory cosmetic result.

Rationale 3: This is an important consideration but is not the most important information for the nurse to share.

Rationale 4: This may be the case, but it is not the most important information for the nurse to share.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-8

Question 20

Type: MCSA

A female patient recovering from a burn to the left side of her face tells the nurse that she has no idea how she is going to return home and resume her regular life since she is so ugly and disfigured. What nursing response is indicated?

1. It is good that your work does not include having to meet the public everyday.

2. I dont think your scars are so bad.

3. I think you should see a plastic surgeon before you try to go back to work.

4. Would you like a referral to the Phoenix Society?

Correct Answer: 4

Rationale 1: This statement reinforces that the patient needs to hide from others and is not appropriate.

Rationale 2: This statement devalues the patients concern and is not appropriate.

Rationale 3: Suggesting plastic surgery reinforces the idea that the patient should not be seen in public and is not appropriate.

Rationale 4: The Phoenix Society maintains a registry of professionals who specialize in scar therapy and camouflage makeup techniques. This offer of a referral addresses the patients concerns, but puts the patient in charge of her decision.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-8

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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