Question Guide

Special medical surgical nursing

2nd year _ 2nd Semester
2020/2021

True & False

Read the following questions and select (T) if the statement is true and
(F) if it is false, then put your answer in the answer sheet

Statement T F
The importance of 8–10 hours of sleep per night should be stressed T
to the patient with rheumatoid arthritis.
Hydroxychloroquine is a medication which can cause blindness in T
patients with rheumatoid arthritis.
Less blood supply, regeneration of the disc and arthritis are reasons F
elderly people develop back problems
Osteomyelitis is a bone infection and is not related to rheumatoid T
arthritis.
Pathological fractures are usually the result of severe osteoporosis, T
not arthritis in patients with osteomyelitis.
Prednisone is a corticosteroid it affects sodium and potassium T
balance and carbohydrate metabolism.
Splinting of hands and wrists of the patient with rheumatoid T
arthritis is done to prevent contractures.
Posture and gait will be affected if the patient is experiencing F
sciatica, pain radiating down a leg resulting from pressure on the
dorsal pedies nerve.
Pain, stiffness, and functional impairment are the primary clinical T
manifestations of osteoarthritis.
Non Stroid antinflamatory drugs ( NSAIDs ) are well known for T
causing gastric upset and increasing the risk for peptic ulcer

1
disease, which could cause the patient to vomit blood.
Confusion may be the only clinical sign of a urinary tract infection
in the older adult. T
. Recurrent episodes of urinary tract infections could progress to T
permanent kidney damage.
. Placement of an indwelling catheter to treat urinary incontinence F
decreases the risk for a urinary tract infection.
patient with nocturia should be instructed to schedule the majority T
of fluid intake prior to 4 p.m.
symptoms of renal failure occur when 40% of nephrons become F
non functioning.
Renal calculi larger than 7 mm usually require some form of T
surgical intervention.
Surgical correction of cryptorchidism is usually performed prior to F
the age of 6 months.
Infants with hypospadias should not be circumcised. T
Dehydration is a risk factor for urinary calculi. T
Flank pain is a prominent symptom of hydronephrosis. T
Maintaining proper body alignment is an important part of teaching T
for the patient with osteoarthritis.
Muscle rupture is a complication of a muscle strain. T
Joint pain can result from injury, arthritis, infection, gout, and T
medication.
Traction is used to reduce a fracture, immobilize an extremity, T
lessen muscle spasms, and correct or prevent a deformity.
Patients who are diabetic or are immune compromised are T
contraindicated for an external fixator.
During acute episodes of rheumatoid arthritis the affected joints are T
splinted for rest; they are not exercised.
Osteomyelitis is a bone infection and is not related to rheumatoid T
arthritis.
Splinting of hands and wrists of the patient with rheumatoid T
arthritis is done to prevent contractures.
Bone formation and resorption is a continuous process requiring an T
adequate intake and vitamin D.
The formation of bone is affected by parathyroid growth hormone, T
sex hormones, and thyroid hormone.

2
Mechanical stress increases the deposition of mineral salts and the T
production of collagen fibers.
The other type is cortical bone, which is compact bone that is found T
in the diaphysis or shaft of the long bones.
The most common complication of peritoneal dialysis is air F
embolism.
Chronic renal failure is a progressive, reversible deterioration in F
renal function.
Controlling diet and electrolytes is important point in dialysis T
patient.
. Patient with allergic reaction from heparin should be perform F
haemodialysis.
Peritoneal dialysis indicated in patient with abdominal adhesion F
. Hemodialysis requires more frequent exchanges than peritoneal F
dialysis but has fewer adverse effects.
Patient undergoing haemodialysis should increase protein intake F
Localized edema and discoloration hours after the injury are T
normal occurrences after a fracture.
Aphasia refers to inability to understand spoken language. F
Medulla oblongata is most responsible for our balance, posture and F
muscle tone.
Number of cranial nerves in human is 22 pairs. F
Nurse should restrain the patient during the seizure to prevent from F
falling.
Risk for injury related to seizure activity is the most priority T
nursing diagnosis in a patient with seizure disorders.
Purpose of an electroencephalogram (EEG) is to measure activty of T
the brain.
To avoid autonomic dysreflexia nurse should avoid noxious T
stimuli.
Side effects of antiplatelets are dizziness, diarrhea, and abdominal T
pain
The priority for interdisciplinary care for the patient experiencing a T
migraine headache is pain management.
Medications such as estrogen supplements may actually trigger a T
migraine headache attack.

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Constrictive clothing, especially around the patient’s neck, can T

interfere with oxygenation.

The priority action during a generalized tonic-clonic seizure is to T
protect the airway.
Side effect of anticoagulant is cardiac dysrhythmias. F
Administer Dilantin to prevent seizure activity. F
During an episode of autonomic dysreflexia the nurse should Put T
the patient in the high-Fowler’s position
Headache in the morning is symptoms of increase intracranial T
pressure.
Give analgesia on schedualed should be done to reduce pain for
brain tumor patient. T
Tegratol is adrug useed for all epilpsy patient. F
The first major effect of increasing intra cranial pressure is a T
decrease in cerebral perfusion causing hypoxia.
Petite mal seizure is characterized by loss of consciousness drop F
his head, talking interrupted.
Maximum score of verbal response is 5 degree. T
Mannitol is a hyperosmolar diuretic that draws fluid from brain T
tissue into the bloodstream.
Patient with epileptic may experience headache, fatigue, confusion T
and nausea after postictal phase.
A postlumbar puncture headache is prevented by instructed patient F
to lie flat for at least 2 hours
Bradycardia occurs for patient with increase intracranial pressure T
due to pressure on vagus nerve .
Normal intra cranial pressure is 25 mm Hg. F
Warfarin sodium is given to stroke patient to prevent thrombi. T
Normal finding from the Babinski reflex is downward curl of the T
toes.
Increasing intra cranial pressure causes an increase in the systolic T
pressure.
Ask the patient to place a heel on the opposite knee to assess arm F
co-ordination.
Symptoms of neurogenic shock include hypotension, tachycardia, F
and warm, dry skin.

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Quick intake of ice-creams can also trigger a headache known as F
"ice-cream headache"

Carbon monoxide poisoning is the most common F

gastrointestinal injury with burns.
Natural depridement using surgical scissors and forceps to F
separate and remove the eschar.
Weight choose to determine if a patients fluid volume is F
adequate.
Urine output choose to determine if a patients fluid volume is T
adequate
The burning process stops once the flames are out F
A superficial burn known as a 1st degree burn, and has damage T
only to the dermis.
48 hrs after the burn, the patient will start to diuresis--fluid is F
going back from the vascular system.
A full-thickness burn is a 3rd degree burn. Damage to the entire T
dermis & fat.
Electric burns can cause significant external damage F
in burns, ADH & aldosterone secreted to excreat Na+ & H2O F
to decrease blood volume
Minor burns should be covered. T
Burn hazards on the job may include contact with steam, flame, T
hot equipment, and certain chemicals.
Electrical burns never require medical attention F
You should never rub a burn T
Don’t use fluffy materials which leaves behind lint and T
promotes infection
Don’t use butter or other ointments which can lead to T
infections with burn injury.
If fingers or toes have burned, separate them with dry sterile, T
non-adhesive dressings.
Place the patient in the shock position if a head, neck, back, or F
leg injury is suspected.
Apply ointment, adhesive bandages, oil spray, to a burn for F
good healing.
Burns in the perineal area are at increased risk for infection. T

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Burns of the face, neck, or chest have the potential to impair T
ventilation.
Use ice to cool the burn F
Destruction of red blood cells at the injury site results in free T
hemoglobin in the urine.
Burns involving the face often associated corneal abrasion
T
Burns of the head, neck, and chest frequently have associated
pulmonary complication. T
Minor Burn Injury ,Second-degree burn of 15-25% total body F
surface area (TBSA) in adults or 10-20% TBSA in children
Put a plaster over a burn to make sure it doesn't get infected. F
Burn hazards on the job may include contact with steam, T
flame, hot equipment, and certain chemicals
Massive cell destruction lead to hypokalemia F
People who experience hydrotherapy an allergic reaction to an F
essential oil should continue its use.
The most serious possible side effect of hydrotherapy is T
overheating, which may occur when an individual spends too
much time in a hot tub or Jacuzzi.

MCQ

6
Read the following statement carefully and circle the correct answer ,
then put your answer in the answer sheet:

The leading cause of end-stage renal disease is:

a. Diabetes mellitus.
b. Hypertension.
c. Glomerulonephritis.
d. Toxic agents.

In chronic renal failure (end-stage renal disease), decreased

glomerular filtration leads to:
a. Increased pH.
b. Decreased creatinine clearance.
c. Increased blood urea nitrogen (BUN).
d. All of the above.

Decreased levels of erythropoietin, a substance normally secreted by

the kidneys, leads to which serious complication of chronic renal
failure?
a. Anemia
b. Acidosis
c. Hyperkalemia
d. Pericarditis

When the nurse caring for a patient with an AV fistula in the forearm
assesses that there is an absence of a “trill” when palpating the
venous side of the fistula, the nurse should:
a. Inject the ordered amount of heparin into the fistula.
b. Apply warm compresses and lower the arm below heart level.
c. Send the patient to dialysis for remedy.
d. Report to the charge nurse that the fistula is occluded.

The nurse becomes alarmed when the dialysis patient who is taking
gentamicin (Garamycin)says:
a. “I have a horrible headache.”
b. “Speak up! I can‟t hear you.”

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 c. “I’ve had diarrhea once or twice today.”
d. “I’m thirsty. I can’t get enough water.”

Patients with chronic renal failure who are receiving dialysis are
prone to injury because of:
a. Bone demineralization, peripheral neuropathy.
b. Fatigue, drug side effects.
c. Impaired immune response, malnutrition.
d. Multiple life changes, hormone deficiencies.

The nurse is teaching the patient how to use a cane. Which of the
following statements is most inaccurate? a- The patient should
hold the cane on the involved side. b- The patient should hold the
cane close to his body. c- The stride length and the timing of each step
should be equal.
d- The nurse should stand behind the patient to prevent falls.

The nurse is assessing a patients burn for the zones of injury. Which
of the following will the nurse not assess in the patient at this time? a.
Zone of coagulation
b. Zone of eschar
c. Zone of hyperemia
d. Zone of stasis
Which of the following will the nurse most likely assess in a patient
diagnosed with a second-degree burn?
a. No pain and necrotic areas
b. No pain and scarring
c. Pain and blisters
d. Pain and peeling after 2 to 5 days

The nurse, caring for a patient with severe burns, realizes that the
patients care will progress through specific periods of treatment
EXCEPT:
a. Acute period.
b. Emergent period.
c. Rehabilitation period.
d. Stabilization period.

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A nurse is admitting a patient with a severe migraine headache and a
history of acute coronary syndrome. What migraine medication
would the nurse question for this patient?
a .Rizatriptan (Maxalt)
b. Naratriptan (Amerge)
c.Sumatriptan succinate (Imitrex)
d.Zolmitriptan (Zomig)

The nurse is caring for a patient with increased intracranial pressure

(ICP). The patient has a nursing diagnosis of ineffective cerebral
tissue perfusion. What would be an expected outcome that the nurse
would document for this diagnosis?
a.Copes with sensory deprivation.
b.Registers normal body temperature.
c.Pays attention to grooming.
d.Obeys commands with appropriate motor responses.

A patient exhibiting an altered level of consciousness (LOC) due to

blunt-force trauma to the head is admitted to the ED. The physician
determines the patients injury is causing increased intracranial
pressure (ICP). The nurse should gauge the patients LOC on the
results of what diagnostic tool?
a.Monro-Kellie hypothesis
b.Glasgow Coma Scale
c.Cranial nerve function
d.Mental status examination

While completing a health history on a patient who has recently

experienced a seizure, the nurse would assess for what characteristic
associated with the postictal state?
a.Epileptic cry
b.Confusion
c.Urinary incontinence
d.Body rigidity

A patient with increased ICP has a ventriculostomy for monitoring

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ICP. The nurses most recent assessment reveals that the patient is
now exhibiting nuchal rigidity and photophobia. The nurse would be
correct in suspecting the presence of what complication?
a.Encephalitis
b.CSF leak
c.Meningitis
d.Catheter occlusion

The nurse is participating in the care of a patient with increased ICP.

What diagnostic test is contraindicated in this patients treatment?
a.Computed tomography (CT) scan
b.Lumbar puncture
c.Magnetic resonance imaging (MRI
d.Venous Doppler studies

The nurse is caring for a patient who is in status epilepticus. What

medication does the nurse know may be given to halt the seizure
immediately?
a.Intravenous phenobarbital (Luminal
b.Intravenous diazepam (Valium)
c.Oral lorazepam (Ativan)
d.Oral phenytoin (Dilantin)

The nurse has created a plan of care for a patient who is at risk for
increased ICP. The patients care plan should specify monitoring for
what early sign of increased ICP?
a.Disorientation and restlessness
b.Decreased pulse and respirations
c.Projectile vomiting
d.Loss of corneal reflex
A clinic nurse is caring for a patient diagnosed with migraine
headaches. During the patient teaching session, the patient questions
the nurse regarding alcohol consumption. What would the nurse be
correct in telling the patient about the effects of alcohol?
a.Alcohol causes hormone fluctuations.
b.Alcohol causes vasodilation of the blood vessels.
c.Alcohol has an excitatory effect on the CNS.
d.Alcohol diminishes endorphins in the brain.

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During the examination of an unconscious patient, the nurse observes
that the patients pupils are fixed and dilated. What is the most
plausible clinical significance of the nurses finding?
a.It suggests onset of metabolic problems.
b.It indicates paralysis on the right side of the body.
c.It indicates paralysis of cranial nerve X.
d.It indicates an injury at the midbrain level.

The nurse is providing care for a patient who is withdrawing from

heavy alcohol use. The nurse and other members of the care team are
present at the bedside when the patient has a seizure. In preparation
for documenting this clinical event, the nurse should note which of
the following?
a.The ability of the patient to follow instructions during the seizure.
b.The success or failure of the care team to physically restrain the
patient.
c.The patients ability to explain his seizure during the postictal
period.
d.The patients activities immediately prior to the seizure.

The nurse is caring for a patient whose recent health history includes an
altered LOC. What should be the nurses first action when assessing this
patient?
a.Assessing the patients verbal response
b.Assessing the patients ability to follow complex commands
c.Assessing the patients judgment
d.Assessing the patients response to pain

The nurse is caring for a patient with a brain tumor. What drug would the
nurse expect to be ordered to reduce the edema surrounding the tumor?
a. Solumedrol
b. Dextromethorphan
c. Dexamethasone
d. Furosemide

A patient has experienced a seizure in which she became rigid and then
experienced alternating muscle relaxation and contraction. What type of
seizure does the nurse recognize?
a. Unclassified seizure

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 b. Absence seizure
c. Generalized seizure
d. .Focal seizure
When caring for a patient with increased ICP the nurse knows the
importance of monitoring for possible secondary complications,
including syndrome of inappropriate antidiuretic hormone (SIADH).
What nursing interventions would the nurse most likely initiate if the
patient developed SIADH?
a. Fluid restriction
b. Transfusion of platelets
c. Transfusion of fresh frozen plasma (FFP)
d. Electrolyte restriction

A patient is recovering from intracranial surgery performed

approximately 24 hours ago and is complaining of a headache that the
patient rates at 8 on a 10-point pain scale. What nursing action is most
appropriate?
a. Administer morphine sulfate as ordered.
b. Reposition the patient in a prone position.
c. Apply a hot pack to the patients scalp.
d. Implement distraction techniques.
A school nurse is called to the playground where a 6-year-old girl has
been found unresponsive and staring into space, according to the
playground supervisor. How would the nurse document the girls
activity in her chart at school?
a. Generalized seizure
b. Absence seizure
c. Focal seizure
d. Unclassified seizure

A neurologic nurse is reviewing seizures with a group of staff nurses.

How should this nurse best describe the cause of a seizure?
a. Sudden electrolyte changes throughout the brain
b. A dysrhythmia in the peripheral nervous system
c. A dysrhythmia in the nerve cells in one section of the brain
d. Sudden disruptions in the blood flow throughout the brain

12
 The nurse is caring for a patient who has undergone supratentorial
removal of a pituitary mass. What medication would the nurse expect
to administer prophylactically to prevent seizures in this patient?
a. Prednisone
b. Dexamethasone
c. Cafergot
d. Phenytoin
A hospital patient has experienced a seizure. In the immediate
recovery period, what action best protects the patients safety?
a. Place the patient in a side-lying position.
b. Pad the patients bed rails.
c. Administer antianxiety medications as ordered.
d. Reassure the patient and family members.

A nurse is caring for a patient who experiences debilitating cluster

headaches. The patient should be taught to take appropriate
medications at what point in the course of the onset of a new
headache?
a. As soon as the patients pain becomes unbearable
b. As soon as the patient senses the onset of symptoms
c. Twenty to 30 minutes after the onset of symptoms
d. When the patient senses his or her symptoms peaking

A nurse is collaborating with the interdisciplinary team to help

manage a patients recurrent headaches. What aspect of the patients
health history should the nurse identify as a potential contributor to
the patients headaches?
a. The patient leads a sedentary lifestyle.
b. The patient takes vitamin D and calcium supplements.
c. .The patient takes vasodilators for the treatment of angina.
d. .The patient has a pattern of weight loss followed by weight gain.

A patient has had an ischemic stroke and has been admitted to

the medical unit. What action should the nurse perform to best
prevent joint deformities?
a. Place the patient in the prone position for 30 minutes/day.
b. Assist the patient in acutely flexing the thigh to promote
movement.

13
 c. Place a pillow in the axilla when there is limited external
rotation.
d. Place patients hand in pronation.

A patient diagnosed with transient ischemic attacks (TIAs) is

scheduled for a carotid endarterectomy. The nurse explains that
this procedure will be done for what purpose?
a. To decrease cerebral edema
b. To prevent seizure activity that is common following a TIA
c. To remove atherosclerotic plaques blocking cerebral flow
d. To determine the cause of the TIA

When caring for a patient who had a hemorrhagic stroke, close

monitoring of vital signs and neurologic changes is imperative. What is
the earliest sign of deterioration in a patient with a hemorrhagic stroke
of which the nurse should be aware?
a. Generalized pain
b. Alteration in level of consciousness (LOC
c. Tonicclonic seizures
d. Shortness of breath

The nurse is performing stroke risk screenings at a hospital open

house. The nurse has identified four patients who might be at risk for
a stroke. Which patient is likely at the highest risk for a hemorrhagic
stroke?
a. White female, age 60, with history of excessive alcohol intake
b. White male, age 60, with history of
uncontrolled hypertension
c. Black male, age 60, with history of diabetes
d. Black male, age 50, with history of smoking

The nurse is preparing health education for a patient who is being

discharged after hospitalization for a hemorrhagic stroke. What
content should the nurse include in this education?
a. Mild, intermittent seizures can be expected.

14
 b. Take ibuprofen for complaints of a serious headache.
c. Take antihypertensive medication as ordered.
d. Drowsiness is normal for the first week after discharge.

A patient is brought by ambulance to the ED after suffering what the

family thinks is a stroke. The nurse caring for this patient is aware
that an absolute contraindication for thrombolytic therapy is what?
a. Evidence of hemorrhagic stroke
b. Blood pressure of 180/110 mm Hg
c. Evidence of stroke evolution
d. Previous thrombolytic therapy within the past 12 months

A patient with possible bacterial meningitis is admitted to the ICU.

What assessment finding would the nurse expect for a patient with
this diagnosis?
a. Pain upon ankle dorsiflexion of the foot
b. Neck flexion produces flexion of knees and hips
c. Inability to stand with eyes closed and arms extended without
swaying
d. Numbness and tingling in the lower extremities

A male patient presents to the clinic complaining of a headache. The

nurse notes that the patient is guarding his neck and tells the nurse
that he has stiffness in the neck area. The nurse suspects the patient
may have meningitis. What is another well-recognized sign of this
infection?
a. Negative Brudzinskis sign
b. Positive Kernigs sign
c. Hyperpatellar reflex
d. Sluggish pupil reaction

To prevent a postlumbar puncture headache, the patient is instructed

to lie flat for at least:
a. 8 hours.
b. 6 hours.

15
 c. 4 hours.
d. 2 hours.

What is the priority nursing diagnosis for a patient experiencing a

migraine headache?
a. Risk for Side effects related to medical therapy.
b. Acute pain related to biologic and chemical factors.
c. Anxiety related to change in or threat to health status.
d. Hopelessness related to deteriorating physiological condition.

The patient with migraine headaches has a seizure. After the seizure,
which action can you delegate to the nursing assistant?
a. Document the seizure.
b. Perform neurologic checks.
c. Take the patient‟s vital signs.
d. Restrain the patient for protection.

You are preparing to admit a patient with a seizure disorder. Which

of the following actions can you delegate to assistant nurse?
a. Complete admission assessment.
b. Set up oxygen and suction equipment.
c. Place a padded tongue blade at bedside.
d. Pad the side rails before patient arrives

A nursing student is teaching a patient and family about epilepsy

prior to the patient‟s discharge. For which statement should you
intervene?
a. “You should avoid consumption of all forms of alcohol.”
b. “Wear your medical alert bracelet at all times.”
c. “Protect your loved one’s airway during a seizure.”
d. “It‟s OK to take over-the-counter medications.”

The nurse is caring for a patient who suddenly develops a tonicclonic

seizure. Which nursing action is most appropriate during a seizure?
a. Forcing a padded tongue blade into the patient’s mouth.
b. Restraining the patient’s limbs.

16
 c. Placing the patient in a supine position.
d. Loosening constrictive clothing.

You are providing care for a patient with an acute hemorrhage

stroke. The patient‟s husband has been reading a lot about strokes
and asks why his wife did not receive alteplase. What is your best
response?
a. “Your wife was not admitted within the time frame that alteplase is
usually given.”
b. “This drug is used primarily for patients who experience an acute
heart attack.”
c. “Alteplase dissolves clots and may cause more bleeding into
your wife‟s brain.”
d. Your wife had gallbladder surgery just 6 months ago and this
prevents the use of alteplase.”

The nurse is discussing the purpose of an electroencephalogram

(EEG) with the family of a patient with massive cerebral hemorrhage
and loss of consciousness. It would be most accurate for the nurse to
tell family members that the test measures which of the following
conditions?
a. Extent of intracranial bleeding.
b. Sites of brain injury.
c. Activity of the brain.
d. Percent of functional brain tissue.

A patient has signs of increased ICP. Which of the following is an

early indicator of deterioration in the patient‟s condition?
a. Widening pulse pressure.
b. Decrease in the pulse rate.
c. Dilated, fixed pupil.
d. Decrease in LOC.

17
A patient is beginning the initial treatment of a major burn in the
emergency room. Which of the following interventions would not be
completed?
a. Inserting an indwelling urinary catheter
b. Intubatng the patient
c. Giving oral medications for pain management
d. Starting an intravenous solution of Ringers lactate
The formula used to calculate the volume of intravenous (IV) fluid
required for fluid resuscitation of a patient receiving care in the first
24 hours after a burn is:
a. 1 to 2 mL of lactated Ringers solution body weight percent burn.
b. 2 to 3 mL of lactated Ringers solution body weight percent burn.
c. 2 to 4 mL of lactated Ringers solution body weight percent
burn.
d. 3 to 6 mL of lactated Ringers solution body weight percent burn.

A patient is being evaluated in the emergency department following a

burn injury at home. The patient has second- and third-degree burns
to the right and left arms, back, and both posterior legs. Using the
rule of nines, the nurse would calculate this patients burn as being:
a. 36 %
b. 45 %
c. 45 %
d. 63 %.

What is the primary goal that the nurse should establish for a patient
with an open wound?
a. The wound will remain free of infection throughout the healing
process.
b. Patient completes antibiotic treatment as ordered.
c. The wound will remain free of scar tissue at healing.
d. Patient increases caloric intake throughout the healing process.

The nurse admitting a patient with significant burns to the

emergency department notes the presence of symptoms consistent
with an inhalation burn. Which finding is the nurse most likely
noting?

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 a. Full-thickness burns to chest
b. Hypotension
c. Agitation
d. Persistent coughing

The Parkland fluid resuscitation calculation calls for 8000 mL. The
burn occurred at noon. The present time is 2:00 PM. The fluid should
be set to deliver _____ mL by _____ PM.
a. 6022 ,2222
b. 0022 ,3222
c. 0022 ,4222
d. 7000, 9:00
a urometer on the catheter of the adult patient with a burn in order
to measure hourly urine output. The nurse is aware that a minimum
acceptable urine output is _____ mL/hr.
a. 12
b. 22
c. 03
d. 40

To prevent contractures in the burn patient, the nurse should:

a. Assist the patient to ambulate as soon as fluid shift has stabilized.
b. Leave the limbs in full extension.
c. Stop range-of-motion (rom) exercises when the patient complains of
pain.
d. Place the limbs in the flexion position.

What statement indicates the patient needs further education

regarding the skin grafting (allografting)?
a. “Because the graft is my own skin, there is no chance it won‟t
„take.'”
b. “For the first few days after surgery, the donor sites will be
painful.”
c. “I will have some scarring in the area when the skin is removed for
grafting.”

19
 d. “I am still at risk for infection after the procedure.”

When providing care for a patient with an acute burn injury, which
nursing intervention is most important to prevent infection by auto
contamination?
a. Avoiding sharing equipment such as blood pressure cuffs between
patients
b. Changing gloves between wound care on different parts of the
patient‟s body
c. Using the closed method of burn wound management
d. Using proper and consistent handwashing
contamination.

Which assessment finding assists the nurse in confirming inhalation

injury?
a. Brassy cough
b. Decreased blood pressure
c. Nausea
d. Headache

Which finding indicates that fluid resuscitation has been successful

for a patient with a burn injury?
a. Hematocrit = 60%
b. Heart rate = 130 beats/min
c. Increased peripheral edema
d. Urine output = 50 mL/hr

Which finding indicates to the nurse that a patient with a burn injury
has a positive perception of his appearance?
a. Allowing family members to change his dressings
b. Discussing future surgical reconstruction
c. Performing his own morning care
d. Wearing the pressure dressings as ordered

Which finding indicates to the nurse that the patient understands the
psychosocial impact of his severe burn injury?
a. “It is normal to feel depressed.”

20
 b. “I will be able to go back to work immediately.”
c. “I will not feel anger about my situation.”
d. “Once I get home, things will be normal.”

Which finding is characteristic during the emergent period after a

deep full thickness burn injury?
a. Blood pressure of 170/100 mm Hg
b. Foul-smelling discharge from wound
c. Pain at site of injury
d. Urine output of 10 mL/hr

Which is the priority nursing diagnosis during the first 24 hours for a
patient with chemical burns to the legs and arms that are red in
color, edematous, and without pain?
a. Decreased Tissue Perfusion
b. Disturbed Body Image
c. Risk for Disuse Syndrome
d. Risk for Ineffective Breathing Pattern

Which laboratory result, obtained on a patient 24 hours post-burn

injury, will the nurse report to the physician immediately?
a. Arterial pH, 7.32
b. Hematocrit, 52%
c. Serum potassium,7.5 mmol/L (mEq/L)
d. Serum sodium, 131 mmol/L (mEq/L)

Which nursing intervention is likely to be most helpful in providing

adequate nutrition while the patient is recovering from a thermal
burn injury?
a. Allowing the patient to eat whenever he or she wants
b. Beginning parenteral nutrition high in calories
c. Limiting calories to 3000 kcal/day
d. Providing a low-protein, high-fat diet

21
Which statement indicates that a patient with facial burns
understands the need to wear a facial pressure garment?
a. “My facial scars should be less severe with the use of this
mask.”
b. “The mask will help protect my skin from sun damage.”
c. “This treatment will help prevent infection.”
d. “Using this mask will prevent scars from being permanent.”
Rational: The purpose of wearing the pressure garment over burn
injuries for up to 1 year is to prevent hypertrophic scarring and
contractures from forming. The pressure garment will not alter the
risk for infection.

The patient with a dressing covering the neck is experiencing some

respiratory difficulty. What is the nurse‟s best first action?
a. Administer oxygen.
b. Loosen the dressing.
c. Notify the emergency team.
d. Document the observation as the only action.

During the acute phase, the nurse applied gentamicin sulfate (topical
antibiotic) to the burn before dressing the wound. Which
manifestation indicates that the patient is having an adverse reaction
to this topical agent?
a. Increased wound pain 30 to 40 minutes after drug application
b. Presence of small, pale pink bumps in the wound beds
c. Decreased white blood cell count
d. Increased serum creatinine level

The burned patient relates the following history of previous health

problems. Which one should alert the nurse to the need for alteration
of the fluid resuscitation plan?
a. Seasonal asthma
b. Hepatitis B 10 years ago
c. Myocardial infarction 1 year ago
d. Kidney stones within the last 6 month

22
The newly admitted patient has burns on both legs. The burned areas
appear white and leather-like. No blisters or bleeding are present,
and the patient states that he or she has little pain. How should this
injury be categorized?
a. Superficial
b. Partial-thickness superficial
c. Partial-thickness deep
d. Full thickness

The newly admitted patient has a large burned area on the right arm.
The burned area appears red, has blisters, and is very painful. How
should this injury be categorized?
a. Superficial
b. Partial-thickness superficial
c. Partial-thickness deep
d. Full thickness
Rational: The characteristics of the wound meet the criteria for a
superficial partial thickness injury (color that is pink or red; blisters;
pain present and high).
Which patient factors should alert the nurse to potential increased
complications with a burn injury?
a. The patient is a 26-year-old male.
b. The patient has had a burn injury in the past.
c. The burned areas include the hands and perineum.
d. The burn took place in an open field and ignited the patient’s
clothing.

The burned patient is ordered to receive intravenous cimetidine,

when the patient‟s family asks why this drug is being given, what is
the nurse‟s best response?
a. “To increase the urine output and prevent kidney damage.”
b. “To stimulate intestinal movement and prevent abdominal
bloating.”
c. “To decrease hydrochloric acid production in the stomach and
prevent ulcers.”

23
 d. “To inhibit loss of fluid from the circulatory system and prevent
hypovolemic shock.”

At what point after a burn injury should the nurse be most alert for
the complication of hypokalemia?
a. Immediately following the injury
b. During the fluid shift
c. During fluid remobilization
d. During the late acute phase

What clinical manifestation should alert the nurse to possible carbon

monoxide poisoning in a patient who experienced a burn injury
during a house fire?
a. Pulse oximetry reading of 80%
b. Expiratory stridor and nasal flaring
c. Cherry red color to the mucous membranes
d. Presence of carbonaceous particles in the sputum

What clinical manifestation indicates that an escharotomy is needed

on a circumferential extremity burn?
a. The burn is full thickness rather than partial thickness.
b. The patient is unable to fully pronate and supinate the extremity.
c. Capillary refill is slow in the digits and the distal pulse is absent.
d. The patient cannot distinguish the sensation of sharp versus dull in
the extremity.

Which type of fluid should the nurse expect to prepare and

administer as fluid resuscitation during the emergent phase of burn
recovery?
a. Colloids
b. Crystalloids
c. Fresh-frozen plasma
d. Packed red blood cells

The patient who experienced an inhalation injury 6 hours ago has

been wheezing. When the patient is assessed, wheezes are no longer
heard. What is the nurse‟s best action?

24
 a. Raise the head of the bed.
b. Notify the emergency team.
c. Loosen the dressings on the chest.
d. Document the findings as the only action.

Ten hours after the patient with 50% burns is admitted, her blood
glucose level is 90 mg/dL. What is the nurse‟s best action?
a. Notify the emergency team.
b. Document the finding as the only action.
c. Ask the patient if anyone in her family has diabetes mellitus.
d. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

On admission to the emergency department the burned patient‟s

blood pressure is 90/60, with an apical pulse rate of 122. These
findings are an expected result of what thermal injury–related
response?
a. Fluid shift
b. Intense pain
c. Hemorrhage
d. Carbon monoxide poisoning

Which clinical manifestation indicates that the burned patient is

moving into the fluid remobilization phase of recovery?
a. Increased urine output, decreased urine specific gravity
b. Increased peripheral edema, decreased blood pressure
c. Decreased peripheral pulses, slow capillary refill
d. Decreased serum sodium level, increased hematocrit

What is the priority nursing diagnosis during the first 24 hours for a
patient with full-thickness chemical burns on the anterior neck, chest,
and all surfaces of the left arm?
a. Risk for Ineffective Breathing Pattern
b. Decreased Tissue Perfusion
c. Risk for Disuse Syndrome
d. Disturbed Body Image

25
The patient has experienced an electrical injury, with the entrance
site on the left hand and the exit site on the left foot. What are the
priority assessment data to obtain from this patient on admission?
a. Airway patency
b. Heart rate and rhythm
c. Orientation to time, place, and person
d. Current range of motion in all extremities

In assessing the patient‟s potential for an inhalation injury as a result

of a flame burn, what is the most important question to ask the
patient on admission?
a. “Are you a smoker?”
b. “When was your last chest x-ray?”
c. “Have you ever had asthma or any other lung problem?”
d. “In what exact place or space were you when you were
burned?”

Which information obtained by assessment ensures that the patient‟s

respiratory efforts are currently adequate?
a. The patient is able to talk.
b. The patient is alert and oriented.
c. The patient‟s oxygen saturation is 97%.
d. The patient’s chest movements are uninhibited

The burned patient‟s family asks at what point the patient will no
longer be at increased risk for infection. What is the nurse‟s best
response?
a. “When fluid remobilization has started.”
b. “When the burn wounds are closed.”
c. “When IV fluids are discontinued.”
d. “When body weight is normal.”

The burned patient on admission is drooling and having difficulty

swallowing. What is the nurse‟s best first action?
a. Assess level of consciousness and pupillary reactions.

26
b. Ask the patient at what time food or liquid was last consumed
c. Auscultate breath sounds over the trachea and mainstem bronchi
d. Measure abdominal girth and auscultate bowel sounds in all four
quadrants

A patient is 1 day post surgery for a crushed pelvis. The nurse

reports that the patient is complaining of being short of breath and
demonstrating signs of confusion and restlessness. The nurse
suspects from these signs alone that the patient has suffered: a.
Impending shock.
b. A fat embolus.
c. Anxiety.
d. Neurovascular compromise.
1. The patient who has osteomyelitis following multiple
fractures inquires what the physician meant when he said that
surgery would follow the antibiotic therapy. The nurse‟s most
helpful reply is to explain that the surgery will be done to: a-
Remove dead bone. b- Close the open draining wound. c-
Close the area with casting material. d- Amputate.

Because the patient has a compound fracture, the nurse should: a-

Limit narcotics for 8 hours after surgery.
b- Monitor the patient’s respirations every hour.
c- Assess for pulses distal to the injury. d- Verify that the patient is
not allergic to sulfa.
The nurse performing a neurovascular assessment of the patient in
skeletal traction assesses the abnormal sign of: a- Delayed
capillary refill. b- Bilateral equal pulses. c- Absence of pain and
swelling. d- Area is same color as unaffected side.
After surgery to treat a hip fracture, a patient returns from the
postanesthesia care unit to the medical-surgical unit.
Postoperatively, how should the nurse position the
patient? a- With the affected hip flexed acutely b- With
the leg on the affected side abducted c- With the leg on
the affected side adducted
d- With the affected hip rotated externally

27
When asked about organisms causing urinary tract infections, which
bacteria would the nurse identify as the most common cause?
a. Streptococcus
b. Escherichia coli (E.coli)
c. Staphylococcus
d. Bacillus anthracis

You note that your patient with chronic renal failure has urine
specific gravity (SG) of 1.035. You explain to the patient that this
specific gravity:
a. Is normal.
b. Indicates very concentrated urine and you recommend increased
fluid intake.
c. Indicates the presence of a urinary tract infection.
d. Indicates dilute urine due to the kidneys‟ lack of ability to
concentrate urine.

Which of the following findings from a urinalysis would most likely

indicate renal dysfunction?
a. Positive leukocyte esterase
b. Positive urobilinogen
c. Positive protein
d. Positive nitrites

During the nursing assessment of the patient with renal insufficiency,

the nurse asks the patient specifically about a history of:
a. Angina
b. Asthma
c. Hypertension
The nurse is discussing osteoporosis with a group of women. Which
factor will the nurse identify as a nonmodifiable risk factor?
a. Calcium deficiency.
b. Tobacco use.
c. Female gender.
d. High alcohol intake.

28
 Which of the following is the most appropriate nursing diagnosis
for a patient with a strained ankle? a- Impaired skin integrity b-
Impaired physical mobility c- Risk for deficient fluid volume
d- Disturbed body image

The nurse is caring for a patient with a cast on the left arm. Which
assessment finding is most significant for this patient? a- Normal
capillary refill in the great toe b- Presence of a normal popliteal pulse
c- Intact skin around the cast edges
d- Ability to move all toes

A patient is on bed rest after sustaining injuries in a car accident.

Which nursing action would help the patient avoid complications
of immobility?
a- Decreasing fluid intake to ease dependent edema b- Turning the
patient every 2 hours and massaging bony prominences
c- Raising the head of the bed to maximize the patient's lung inflation d-
Bathing and feeding the patient to decrease energy expenditure

After a traumatic back injury, a patient requires skeletal traction.

When caring for this patient, the nurse must:
a- Change the patient's position only if ordered by the physician. b-
Maintain traction continuously to ensure its effectiveness.
c- Support the traction weights with a chair or table to prevent accidental
slippage.
d-Restrict the patient's fluid and fiber intake to reduce the movement
required for bedpan use.

The nurse working on a urology hospital unit monitors patients for

urosepsis. The nurse would recognize that the population most at risk
for the development of urosepsis is
a. Females
b. Males
c. Elderly
d. Athletes

29
1. Figure 3 represents what type of bone fracture:
A. Closed Fracture B. Compound Fracture C. Greenstick Fracture D.
Transverse Fracture
A patient with rheumatoid arthritis is experiencing sudden vision
changes. Which medication found in the patient‟s medication list can
cause retinal damage?
A. Hydroxychloroquine (Plaquenil) B. Lefluomide (Arava) C.
Sulfasalazine (Azulfidine)
D. Methylprednisolone (Medrol)
The nurse is evaluating a patient for a urinary tract infection. To
correctly assess for costovertebral angle tenderness, the nurse would
a. Use fist percussion the posterior chest below rib cage.
b. Have the patient contract pelvic floor muscles for 10 seconds,
c. Apply pressure over symphysis pubis. D.Have the patient contract
abdominal muscles

What volume of daily fluid intake is recommended for a healthy

adult?” The patient that best understands the concept is the patient
who answers
a. 750 ml/d b.1000 ml/d c.2000 ml/d d.3000 ml/d

A 75-year-old patient with renal insufficiency is admitted to the

hospital with pneumonia. He's being treated with gentamicin
(Garamycin), which can be nephrotoxic. Which laboratory value
should be closely monitored?
a.Blood urea nitrogen b.Sodium level c.Alkaline phosphatase d.White
blood cell (WBC) count

A patient with suspected renal insufficiency is scheduled for a

comprehensive diagnostic workup. After the nurse explains the
diagnostic tests, the patient asks which part of the kidney "does the
work." Which answer is correct?
a. The glomerulus b.Bowman's capsule c.The nephron
d.The tubular system

30
A patient with renal dysfunction of acute onset comes to the
emergency department complaining of fatigue, oliguria, and
coffeecolored urine. When obtaining the patient's history to check for
significant findings, the nurse should ask about:
a.Excessive acetaminophen use. C.Recent streptococcal infection.
b.Childhood asthma. D.Family history of
pernicious anemia.

The patient newly diagnosed with chronic renal failure recently has
begun hemodialysis. Knowing that the patient is at risk for
disequilibrium syndrome, the nurse assesses the patient during
dialysis for:
a. Hypertension, tachycardia, and fever c.hypotension , bradycardia, and
hypothermia
b. Restlessness , and generalized weakness d.Deteriorating level of
consciousness, and twitching

A patient presents with a dislocated wrist. The hand on the affected

side is cold and blue. How should the nurse interpret these findings?
a. Bleeding into the soft tissues has occurred. C.Neurovascular
compromise exists.
b. Lymphatic channels are blocked. D.A bone fracture
coexists.

When planning care for a patient with a fractured hip, the nurse
would plan to monitor for which common complications?
a. Urinary tract infection b.Candidiasis c.Herniated nucleus pulposus
d.Thromboembolism

What findings on physical examination of a patient brought into

emergency are consistent with a fractured hip?
a.Lengthening and internal rotation of the affected leg.
b.Lengthening and external rotation of the affected leg.
c.Shortening and internal rotation of the affected leg.
d.Shortening and external rotation of the affected leg.

The nurse is caring for a patient with chronic renal failure. The
laboratory results indicate hypocalcemia and hyperphosphatemia.

31
When assessing the patient, the nurse should be alert for which of the
following? Select all that apply:
a. Cardiac arrhythmias
b. Constipation
c. Decreased clotting time
d. Drowsiness and lethargy

For a patient with renal calcium stone,the nurse should provide

instruction on which of the following diets?
a. Acid-ash with limited intake of calcium and milk products.
b. Alkaline-ash with limited intake of foods high in oxalate.
c. Alkaline-ash with limited intake of foods high in purine.
d. Low cholesterol diet with limited intake of saturated fats.

The nurse is caring for a patient placed in traction to treat a

fractured femur. Which nursing intervention has the highest
priority?
a- Assessing the extremity for neurovascular integrity b-
Keeping the patient from sliding to the foot of the bed c-
Keeping the ropes over the center of the pulley d- Ensuring
that the weights hang free at all times .

The nurse is managing the care of a patient with osteoarthritis.

Appropriate treatment strategies for osteoarthritis
include: a- Administration of narcotics for pain control. b-
Bed rest for painful exacerbations.
c- Administration of nonsteroidal anti-inflammatory drugs
(NSAIDs). d- Vigorous physical therapy for the joints.

Elderly patients who fall are most at risk for which of the following
injuries? a- Wrist fractures b- Humerus fractures c- Pelvic fractures
d- Cervical spine fractures

A patient is admitted with acute osteomyelitis that developed after

an open fracture of the right femur. When planning this patient's
care, the nurse should include which measure? a- Administering

32
 large doses of oral antibiotics as prescribed b- Instructing the patient to
ambulate twice daily c- Withholding all oral intake
d- Administering large doses of I.V. antibiotics as prescribed

The patient has a history of nephrolithiasis. The nurse has completed

the appropriate patient teaching. Which statement by the patient
demonstrates an understanding of the teaching?
e. “I will decrease fluid intake to 1000 ml/d”
f. “will strain urine and save solid material for analysis.”
g. “I will avoid calcium-rich foods or calcium supplements”
h. “I will maintain bed rest with bathroom privileges.”

After being diagnosed with pyelonephritis, the patient asks the

nurse what causes this disorder. The nurse‟s response would be
based on the knowledge that the most common cause of
pyelonephritis is/are
a. Urethritis and cystitis
b. Potassium imbalances
c. Sodium imbalances
d. Uremic syndrome

The nurse observes that the patient‟s urine is dark yellow and
appears very concentrated. The lab test that would correlate with this
data would be:
a. High urine specific gravity
b. Low hemoglobin and hematocrit
c. Elevated WBC count
d. Proteinuria
The nurse is reviewing a patient's fluid intake and output record.
Fluid intake and urine output should relate in which way?
a. Fluid intake should be double the urine output.
b. Fluid intake should be approximately equal to the urine output.
c. Fluid intake should be half the urine output.
d. Fluid intake should be inversely proportional to the urine output.

The nurse is reviewing the report of a patient's urinary tract infection

urine analysis. Which value should the nurse consider abnormal?
33
 a. Specific gravity of 1.03
b. Urine pH of 3.0
c. Absence of protein
d. Absence of glucose

A 69-year-old patient with diabetes mellitus type 2 is to undergo a CT

scan using contrast media. What laboratory test(s) should be performed
prior to the CT scan?
a. Liver function tests c.Electrolytes
b. BUN and creatinine d.Fasting blood sugar

Which of the following is a common complaint of the patient with

end-stage renal failure?
a. Weight loss c.Itching
b. Ringing in the ears d.Bruising
The most common nursing care for the patient with edema is:
a. Administer prescribed medications c.Elevate the leg above
heart level
b. Check vital signs frequently d.All of the
above
Which of the following nursing assessments and interventions should
the nurse implement immediately prior to initiating hemodialysis?
a. Assess arterio-venous fistula for bruit. C.Calculate
total urine output for the night.
b. Assess dietary intake. D.Obtain blood glucose level.
Treatment with hemodialysis is ordered for a patient and an external
shunt is created. Which nursing action would be of highest priority
with regard to the external shunt?
a. Heparinize it daily.
b. Avoid taking blood pressure measurements or blood
samples from the affected arm.
c. Change the Silastic tube daily.
d. Instruct the patient not to use the affected arm.
The nurse assesses a facial characteristic that is a sign of fluid
retention in the patient with renal impairment, which is:
a. Broken blood vessels around the nose. C.Perorbital
edema.

34
 b. Rash on cheeks and neck.
D.Facial twitching.

Which of the following statements is made by patient who has a

fractured hip indicates understanding of “hip precautions”? a. “I
can’t fully extend my leg at the hip for 1 month.”
b. “I won’t be able to cross my knees for at least 12 weeks.”
c. “I can put weight on the affected leg as long as it doesn’t cause
pain.”
d. “I can flex my hip but not more than 90 degrees for up to 2
months.”

Emergent treatment of a simple long bone fracture includes which

of the following measures?
a. Application of heat c.Positioning the limb in a dependent position.
b. Splinting above and below the fracture d.Application of a pressure
bandage

Monitoring for signs of a fat embolus is of particular importance

when caring for a patient with which problem?
a. Degenerative disc disease c.Systemic lupus
erythematosus
b. Osteogenesis imperfect d.Femoral fracture

Emergent care for a patient with a dislocation includes which

intervention?
a. Keeping the area warm c.Putting joint through passive range of
motion
b. Splinting the joint in the dislocated position d.Providing tactile
stimulation distal to the affected joint

A patient newly diagnosed with osteoarthritis asks about the

medication treatments for their condition. Which medication is NOT
typically prescribed for OA?
A. NSAIDs
B. Topical Creams
C. Oral corticosteroids

35
D. Acetaminophen (Tylenol)

Bones play an important role in the body. Which of the following in

NOT a function performed by the bones?
A. Provide protection and support for the organs.
B. Give the body shape.
C. Secrete the hormone calcitonin and store blood cells.
D. Store calcium and phosphorus

A 85 year old patient has an accidental fall while going to the

bathroom without assistance. It appears the patient has sustained a
bone fracture to the left leg. The leg‟s shape is deformed and the
patient is unable to move it. The patient is alert and oriented but in
pain. What will you do FIRST after confirming the patient is safe and
stable?
A. Apply an ice pack covered with a towel to the site.
B. Immobilize the fracture with a splint.
C. Administer pain medication.
D. Elevate the extremity above heart level.

Identify the correct sequence in how rheumatoid arthritis develops:

A. Development of pannus, synovitis, ankylosis
B. Anklyosis, development of pannus, synovitis
C. Synovitis, development of pannus, anklyosis
D. Synovitis, anklyosis, development of pannus

Which of the following is a measurement of the kidney‟s ability to

concentrate urine?
a. Urine osmolality
b. Creatinine clearance
c. Specific gravity
d. Urine cytology

When monitoring a patient for compartment syndrome, which

question should be included in the assessment?
a. Does it hurt when you flex the muscle of your arm?
b. Has the pain increased in your arm?

36
 c. Has the swelling increased near your shoulder?
d. Is there a red line going down your arm?

The nurse is performing an assessment on a patient who has

returned from the dialysis unit following hemodialysis. The
patient is complaining of headache and nausea and is extremely
restless. Which of the following is the most appropriate nursing
action?
a. Monitor the patient.
b. Notify the physician.
c. Elevate the he ad of the bed .
d. Medicate the patient for nausea.

A patient newly diagnosed with renal failure has just been started
on peritoneal dialysis. During the infusion of the dialysate, the
patient complains of abdominal pain. Which action by the nurse is
appropriate?
a. Stop the dialysis.
b. Slow the infusion.
c. Decrease the amount to be infused.
d. Explain that the pain will subside after the first few
exchanges.

The patient arrives at the emergency department with complaints

of low abdominal pain and hematuria. The patient is a febrile. The
nurse next assesses the patient to determine a history of:
a. Pyelonephritis
b. Glomeruloneph ritis
c. Trauma to the bladder or abdomen
d. Renal cancer in the patient’ s family

The nurse is assessing a patient with possible osteoarthritis. The

most significant risk factor for osteoarthritis is: a- Congenital
deformity. b- Age. c- Trauma. d- Obesity.
.A patient is admitted to the hospital with chronic renal failure. The
nurse understands that this condition is characterized by:
a. Confusion with coma..

37
 b. Progressive irreversible destruction of the kidneys
tubules.
c. Rapid decrease in urinary output with elevated BUN.
d. Increase in creatinine clearance with a decrease in urinary
output. .Which of the following nursing diagnosis would be the
priority in a patient with end-stage renal disease?
a. Fluid volume excess
b. Activity intolerance
c. Alterations in comfort
d. Knowledge deficit
As a result of the metabolic acidosis for a patient with chronic renal
failure, the nurse must monitor for which of the following electrolyte
imbalances?
a. Hypokalemia
b. Hyperkalemia
c. Hyponatremia
d. Hypernatremia
The patient with renal failure may develop anemia, which may be
due to:
a. Erythropoietin deficiency.
b. Vit K deficiency.
c. Calcium deficiency.
d. Rennin deficiency.
The nurse is assessing a patient diagnosed with second- and thirddegree
burns. Which of the following assessment signs
would not need to be reported by the nurse?
a. Brassy cough
b. Hoarseness
c. Respiratory rate of 36
d. Urine output of 30 mL in the first hour

A nurse is managing the fluid status of a patient being treated for a

burn. Which of following is an indicator of adequate fluid resuscitation?
a. Blood pressure 95/60 mmHg
b. Pulse 115 bpm
c. Patient confusion

38
 d. Urine output 30 mL/hr

The nurse is initiating care for a patient diagnosed with burns to the
chest, back, neck, and face. For this patient, which of the following
nursing diagnoses would receive the highest priority?
a. Disturbed body image
b. Impaired skin integrity
c. Ineffective airway clearance
d. Risk for infection

A patient is scheduled to receive a skin graft from another species as

part of the treatment for a burn wound. Which of the following is a
graft of skin obtained from another species?
a. Allograft
b. Autograft
c. Heterograft
d. Homograft

A patient is recovering from a skin graft to her right arm. Which of

the following nursing interventions would not be indicated for this
patient?
a. Assess for bleeding.
b. Assess for drainage underneath the graft site.
c. Encourage exercise of the right arm.
d. Remove dressings slowly.

A patient diagnosed with a major burn is being prescribed medication

for pain. The nurse realizes that the drug of choice for this patient will
be:
a. Morphine sulfate.
b. Acetaminophen.
c. Aspirin.
d. Meperidine.

To support the nutritional needs of a patient recovering from a burn

injury, the nurse will prepare to administer which of the following?

39
 a. High carbohydrate diet
b. High fat diet
c. Low protein diet
d. Vitamins C and A supplements

A patients wound is being debrided by letting a wet-to-dry dressing

that is packed into the wound dry. This type of debridement is called:
a. Autolytic debridement.
b. Enzymatic debridement.
c. Mechanical debridement.
d. Sharp debridement.
Which of the following should the nurse instruct a patient who is
prescribed a topical medication for a skin condition? a. Apply directly
to broken or irritated skin.
b. Apply before bathing.
c. Apply after bathing.
d. Cover the area with an occlusive dressing.

What is the function of the stratum corneum? a.

Provides insulation for temperature regulation
b. Provides strength and elasticity to the skin
c. Protects the body against the entry of pathogens
d. Continually produces new skin cells

A patient with quadriplegia presents to the outpatient clinic with an

ischial wound that extends through the epidermis into the dermis.
When documenting the depth of the wound, how would the nurse
classify it?
a. Partial-thickness wound
b. Penetrating wound
c. Superficial wound
d. Full-thickness wound

40
41