Chapter 53- Burns and Common Integumentary Disorders. My Nursing Test Banks

 

1.

A patient has had an alkali splash causing burns to the right upper extremity and the right side of the face. Which intervention by the nurse is a priority?

A)

Obtain a health history.

B)

Irrigate with water to the burned area.

C)

Apply an antibiotic cream.

D)

Start an intravenous line (IV) of normal saline at 10 mL/hr.

2.

A patient arrived in the emergency department (ED) after being found by a family member unconscious in the garage with the car running. High flow oxygen at 100% is administered in the ED. The nurse knows that which of the following diagnostic tests would be the best to determine that the present therapy is effective?

A)

Pulse oximetry

B)

Chest x-ray

C)

Serial carboxyhemoglobin levels

D)

Hemoglobin and hematocrit

3.

A patient has been treated for severe burns over 36% of the body. What assessment data obtained by the nurse indicates the patient may be experiencing septic shock? Select all that apply.

A)

White blood count (WBC) 7,200

B)

Blood pressure 60/40

C)

PaO2 72

D)

Urine output <10 mL/hour

E)

Blood pressure 140/76

4.

The nurse is caring for a patient 24 hours after fluid resuscitation for burns over 50% of the body. Which assessment data obtained by the nurse indicates complications from the fluid resuscitation?

A)

Absent peripheral pulses

B)

Crackles in lung fields

C)

Sinus bradycardia

D)

1+ pitting edema of the feet

5.

The nurse determines that the patient is at the end of the resuscitation phase of the burn injury. What assessment data has the nurse obtained that is a primary indicator of this phase?

A)

Pa02 of 90

B)

A reddish-brown color of urine

C)

Urine output of >30 mL/hr

D)

Urine output of <20 mL/hr

6.

The patient has received a nebulizer treatment with a bronchodilator for the treatment of bronchospasm related to an inhalation injury. What intervention by the nurse can effectively evaluate the effectiveness of this treatment?

A)

Assess breath sounds.

B)

Monitor for cardiac dysrhythmias.

C)

Assess heart rate.

D)

Assess for jugular vein distention.

7.

The nurse is assessing the patient with a circumferential burn to the left upper extremity. The nurse anticipates the performance of an escharotomy with which of the following assessment findings? Select all that apply.

A)

Absent distal radial pulses

B)

Progressive diminution of ultrasound signal

C)

Limited range of motion

D)

Decrease in capillary refill

E)

Pink nail beds

8.

A patient with third degree burns on both lower extremities from a house fire has been in the hospital for two weeks. The patient states, I do not feel like walking today. I am going to stay in bed. What is the best response by the nurse?

A)

I understand. I have days like that too. Go ahead and stay in bed.

B)

I am going to tell the doctor that you were not compliant with the order to get out of bed.

C)

I will allow you to wait until the afternoon, but then you must get up.

D)

It is important for your recovery to walk every day. Lets walk in the hallway for 10 minutes and then get a snack.

9.

A patient is in the ICU with lesions of the chest, back, and extremities. The physician suspects toxic epidermal necrolysis (TEN). What statement by the patient would alert the nurse to the precipitating factor?

A)

I started taking an antibiotic for a respiratory infection.

B)

I was working in the garden planting flowers.

C)

I have been treated for basal cell carcinoma of my nose.

D)

I had a flu shot one month ago.

10.

A patient is admitted into the emergency department with the complaint, I burned my hand. I didnt realize the stove top was still so hot. The palmar surface of the hand is blistered, red, and blanches. What type of burn does the nurse document this patient has?

A)

Superficial

B)

Deep partial thickness

C)

Superficial partial thickness

D)

Full thickness

11.

The patient has an acute burn injury. What might be the cause of the burn trauma? Select all that apply.

A)

Pot of boiling water pulled off a stove

B)

Crockpot full of beans spilled

C)

House or room fire

D)

Absence of electrical power

E)

Exposure to anhydrous ammonia

F)

Contact with white phosphorus

12.

The patient has a superficial partial-thickness (second-degree) burn. What characteristic unique to this type of burn does the nurse expect to find?

A)

Bright red color

B)

Surface moist and supple

C)

Fluid-filled blisters

D)

High pain level

13.

An adult has a thermal burn injury involving all of one leg and the entire posterior trunk. There are also three scattered areas on the anterior trunk, each approximately the size of the patients palm. As part of initial assessment, the nurse calculates the size of the burn using a combination of the Rule of Nines and the Rule of Palm. What is the result of this calculation in percentage of total body surface area (TBSA)?

14.

The underlying pathophysiology of a burn trauma centers around what?

A)

Location of burn damage

B)

Zone of coagulation

C)

Maximum exposure temperature

D)

Extent of cellular injury and death

15.

A patient has a large thermal burn injury and is receiving large amounts of intravenous crystalloid fluid as part of initial therapy. What is the best explanation of the purpose of this therapy?

A)

It is part of the protocol for initial burn management.

B)

Burn trauma cell damage causes external fluid loss.

C)

Development of third spacing reduces renal perfusion.

D)

Crystalloid intravenous fluids are less expensive.

16.

A patient with a large thermal burn injury is found to have depressed cardiac contractility and a resultant low cardiac index. What is the underlying, primary, physiologic rationale for this situation?

A)

Inflammation-triggered release of nitric oxide

B)

Reduction of platelet aggregation and adhesion

C)

Decreased intravascular volume from third spacing

D)

Peripheral vasodilatation from inflammation

17.

A patient has a large burn injury that occurred in an enclosed space. On initial assessment, the patient is found to have erythema and blistering of the mouth and pharynx, hoarse speech, and tachypnea. What immediate therapy addressing these symptoms does the nurse anticipate?

A)

Intravenous fluid resuscitation

B)

Prophylactic antimicrobial therapy

C)

Application of topical burn medications

D)

Endotracheal intubation

18.

A patient with a large thermal burn has been admitted to the burn intensive care unit. Because the leading cause of death in burned patients after the initial care period is infection, what is the nurses priority action?

A)

Ensure compliance with hand hygiene protocols by all health care team members.

B)

Limit visits of legal next of kin to very brief periods of time.

C)

Adhere to clean aseptic principles during wound care and dressing changes.

D)

Collect environmental cultures and wound cultures as scheduled.

19.

In a motor vehicle crash, a patient suffers a skull fracture, possible cervical spine injury, multiple extremity fractures, and a large thermal burn. On initial admission to the emergency department, what is the nursing priority of care?

A)

Intravenous fluid resuscitation

B)

Protection from infection

C)

Assessment of extent of burns

D)

Protection of airway and cervical spine

20.

A patient weighing 65 kg has a deep partial-thickness burn that totals 45% total body surface area (TBSA) and is ordered to receive fluid resuscitation with volumes calculated by the maximum amount from the American Burn Association consensus formula. The burn occurred at 0800 and intravenous fluids are initiated at 1000. For the first 8 hours after the burn, the nurse plans to administer what amount of intravenous lactated Ringers solution in mL/hr?

21.

An adult patient with a large thermal burn has been receiving intravenous fluid resuscitation calculated by the maximum amount according to the American Burn Association consensus formula. What symptom or result would indicate the onset of a complication secondary to rapid fluid resuscitation?

A)

Urine output 30 to 50 mL/hr

B)

Serum sodium 135 to 140 mEq/L

C)

Weight gain of 12% since admission

D)

New coarse crackles auscultated at lung bases

22.

The patient has a large burn wound that is mostly a full-thickness (third-degree) injury. Wound care included surgical excision and grafting with a variety of materials. The patient and family ask the nurse to explain why repeated surgical procedures are necessary. What is the best explanation the nurse can give the family?

A)

Because of pain and surgical shock, the repair is done in stages.

B)

The surgeon is the appropriate person to answer this question.

C)

Successful autografting requires preparation of the wound bed.

D)

Lack of patient compliance has reduced the effectiveness of autografting.

23.

A patient with a healing burn wound involving several joints is being evaluated at a patient care conference. What would indicate an effective collaborative plan of care and functioning of the health care team?

A)

Conference discussion focuses on patient and family goal achievement.

B)

Complication of contractures is blamed on inadequate attention by physical therapy.

C)

Lack of adequate nutritional support is explained by poor patient compliance.

D)

Family and patient have filed complaints of uncaring behaviors by physician.

24.

The patient has been admitted with toxic epidermal necrolysis (TENS) involving 40% total body surface area (TBSA), including the mouth, trunk, and lower extremities. What therapy does the nurse anticipate initiating?

A)

Intravenous antimicrobial therapy

B)

Vigorous physical therapy and walking

C)

Topical corticosteroid therapy

D)

Intravenous fluid and electrolyte replacement

Answer Key

1.

B

2.

C

3.

B, C, D

4.

B

5.

D

6.

A

7.

A, B, D

8.

D

9.

A

10.

C

11.

A, B, C, E, F

12.

C

13.

39%

14.

D

15.

C

16.

A

17.

D

18.

A

19.

D

20.

975

21.

D

22.

C

23.

A

24.

D

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