1.

BURNS MIDTERM TOPIC

2. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to
document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
3. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA)
burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9
mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse
anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
4. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are
heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best
action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
5. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The
initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of
administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour
6. During the emergent phase of burn care, which assessment will be most useful in determining
whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output
7. A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain
adequate nutrition, the nurse should plan to take which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
8. While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action
to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.
9. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The
nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck.
10. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength
and numbness in the toes. Which action should the nurse take?
a. Notify the health care provider.
 b. Monitor the pulses every 2 hours.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes on both feet.
11. Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago.
Which nursing assessment would best evaluate the effectiveness of the medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood
12. The nurse is reviewing the medication administration record (MAR) on a patient with partial-
thickness burns. Which medication is best for the nurse to administer before scheduled wound
debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid)

13. A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and
neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates
that the problem is resolving?
a. "I'm glad the scars are only temporary."
b. "I will avoid using a pillow, so my neck will be OK."
c. "I bet my boyfriend won't even want to look at me anymore."
d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"

14. The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine
output has dramatically increased. Which action by the nurse would best ensure adequate kidney
function?
a. Continue to monitor the urine output.
b. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
d. Prepare the patient for discharge from the burn unit.

15. A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn
treatment. Which snack would be best for the nurse to offer to this patient?
a. Bananas
b. Orange gelatin
c. Vanilla milkshake
d. Whole grain bagel

16. A patient has just arrived in the emergency department after an electrical burn from exposure to a
high-voltage current. What is the priority nursing assessment?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction

17. An employee spills industrial acids on both arms and legs at work. What is the priority action that the
occupational health nurse at the facility should take?
a. Remove nonadherent clothing and watch.
b. Apply an alkaline solution to the affected area.
c. Place cool compresses on the area of exposure.
d. Cover the affected area with dry, sterile dressings.

18. A patient who has burns on the arms, legs, and chest from a house fire has become agitated and
restless 8 hours after being admitted to the hospital. Which action should the nurse take first?
 a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.

19. A patient arrives in the emergency department with facial and chest burns caused by a house fire.
Which action should the nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringer's solution.
d. Administer the ordered hydromorphone (Dilaudid).

20. A patient with extensive electrical burn injuries is admitted to the emergency department. Which
prescribed intervention should the nurse implement first?
a. Assess oral temperature.
b. Check a potassium level.
c. Place on cardiac monitor.
d. Assess for pain at contact points.

21.Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse
assesses the patient. Which information would be a priority to communicate to the health care
provider?
a. Blood pressure is 95/48 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 108.
d. Urine output is 20 mL per hour for the past 2 hours.

22. Which patient should the nurse assess first?

a. A patient with smoke inhalation who has wheezes and altered mental status
b. A patient with full-thickness leg burns who has a dressing change scheduled
c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain
d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

23. Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN)
who has floated from the hospital medical unit?
a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral
feedings.
b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb
aspiration
c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft
to the chest
d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-
thickness facial burns

24.A patient who was found unconscious in a burning house is brought to the emergency department by
ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse
take first?
a. Insert two large-bore IV lines.
b. Check the patient's orientation.
c. Assess for singed nasal hair and dark oral mucous membranes.
d. Place the patient on 100% oxygen using a non-rebreather mask.

25. The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which
result requires priority action by the nurse?
a. Hematocrit 53%
b. Serum sodium 147 mEq/L
 c. Serum potassium 6.1 mEq/L
d. Blood urea nitrogen 37 mg/dL

26. The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which
action by the new nurse would require an intervention by the charge nurse?
a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C).
c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing
change.
d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic
patient's serum glucose is elevated.

27. Which nursing action is a priority for a patient who has suffered a burn injury while working on an
electrical power line?
a. Obtain the blood pressure.
b. Stabilize the cervical spine.
c. Assess for the contact points.
d. Check alertness and orientation.

28.Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a
burn injury to the right arm and chest?
a. Keep the right arm in a position of comfort.
b. Avoid the use of sustained-release narcotics.
c. Teach about the purpose of tetanus immunization.
d. Apply water-based cream to burned areas frequently.

29. A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn
tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by
the nurse is best?
a. "Most people recover after a burn and feel satisfied with their lives."
b. "It's true that your life may be different. What concerns you the most?"
c. "It is really too early to know how much your life will be changed by the burn."
d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

30. In which order will the nurse take these actions when doing a dressing change for a partial-thickness
burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D,
E].)
a. Apply sterile gauze dressing.
b. Document wound appearance.
c. Apply silver sulfadiazine cream.
d. Administer IV fentanyl (Sublimaze).
e. Clean wound with saline-soaked gauze
ANS:
D, E, C, A, B
Because partial-thickness burns are very painful, the nurse's first action should be to administer
pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with
a new sterile dressing. The last action should be to document the appearance of the wound.

31. A patient comes into the emergency department with a chemical burn from contact with
lye .Assessment and treatment of this patient will be based on what knowledge regarding this type of
burn? (Select all that apply)
1. This is an alkali burn.
2. This type of burn tends to be deeper.
3. This is an acid burn.
4. This type of burn will be easier to neutralize.
5. This type of burn tends to be more superficial.
32. Knowing the most common causes of household fires, which prevention strategy would the nurse
focus on when teaching about fire safety?

a. Set hot water temperature at 140 degrees F

b. Use only hardwired smoke detectors
c. Encourage regular home fire exit drills
d. Never permit older adults to cook unattended

33. A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse
prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which
recommendation?

A. The total 24-hour fluid requirement should be administered in the first 8 hours.
B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

34. A patient arrives at the emergency department with an electrical burn. What assessment questions
should the nurse ask in determining the possible severity of the burn injury? Select all that apply.
1. What type of current was involved?
2. How long was the patient in contact with the current?
3. How much voltage was involved?
4. Where was the patient when the burn occurred?
5. What was the point of contact with the current?
35. The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within
the last 12 hours. Upon assessment the nurse would expect to find which manifestation?

A. Blisters
B. Reddening of the skin
C. Destruction of all skin layers
D. Damage to sebaceous glands
36. The injury that is least likely to result in a full-thickness burn is:

a. sunburn
b. scald injury
c. chemical burn
d. electrical injury

37. A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be
the FIRST action by the nurse?
1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the patient to prevent heat loss.
4. Move the patient indoors to a dry place.
5. Get the patient up off the ground
38.The nurse is planning care for a patient with partial- and full-thickness skin destruction related to
burn injury of the lower extremities. Which interventions should the nurse expect to include in this
patient's care? (Select all that apply.)

A. Escharotomy
B. Administration of diuretics
C. IV and oral pain medications
D. Daily cleansing and debridement
39.
When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA):
 a. blisters
b. exposed fascia
c. exposed muscles
d. intact nerve endings
e. red, shiny, wet appearance

40.A patient is admitted to the burn center with burns of his head and neck, chest, and back after an
explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On
reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the
most appropriate for the nurse to take next?

a. obtain vital signs and a STAT ABG

b. encourage the patient to cough and auscultate the lungs again
c. document the findings and continue to monitor the patient's breathing
d. anticipate the need for endotracheal intubation and notify the physician

41. A nurse is teaching a class of older adults at a senior center about household cleaning agents that may
cause burns. Which agents should be included in these instructions?
(Select all that apply)
1. drain cleaners
2. household ammonia
3. oven cleaner
4. toiler bowl cleaner
5. lemon oil furniture polish
42.The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When
planning nutritional interventions for this patient, what dietary choices should the nurse implement?

A. Full liquids only

B. Whatever the patient requests
C. High-protein and low-sodium foods
D. High-calorie and high-protein foods

43. A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the
severity of the burn and how long it will take to heal. With which of the following should the nurse
respond to this patient?
1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
2. The wound is a partial-thickness burn, and could take up to two weeks to heal.
3. The wound is a superficial burn, and will take up to three weeks to heal.
4. The wound is a full-thickness burn and will take one to two weeks to heal.
5. Wound healing is individualized.
44.A patient is admitted to the emergency department with first- and second-degree burns after being
involved in a house fire. Which assessment findings would alert you to the presence of an inhalation
injury? (select all that apply)?

A. Singed nasal hair

B. Generalized pallor
C. Painful swallowing
D. Burns on the upper extremities
E. History of being involved in a large fire
45. Fluid and electrolyte shift that occur during the early emergent phase of a burn injury include:

a. adherence of albumin to vascular walls

 b. movement of potassium into vascular space
c. sequestering of sodium and water in interstitial fluid
d. hemolysis of red blood cells from large volumes of rapidly administered fluid
46. In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to
assess?
Select all that apply.
1. the depth of the burn
2. extent of burns on the body
3. the causative agent and the duration of exposure.
4. location of burns on the body
5. the time that the burn occurred
47. When caring for a patient with an electrical burn injury, which order from the health care provider
should the nurse question?

A. Mannitol 75 gm IV
B. Urine for myoglobulin
C. Lactated Ringer's at 25 mL/hr
D. Sodium bicarbonate 24 mEq every 4 hours
48. To maintain a positive nitrogen balance in a major burn, the patient must:

a. eat a high-protein, low-fat, high-carbohydrate diet

b. increase normal caloric intake by about three times
c. eat at least 1500 calories/day in small, frequent meals
d. eat rice and whole wheat for the chemical effect on nitrogen balance.

49. A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a
silver-impregnated dressing. The nurse's priority intervention for wound care would be to:
a. reapplies a new dressing without disturbing the wound bed
b. observe the wound for signs of infection during dressing changes
c. apply cool compresses for pain relief in between dressing changes
d. wash the wound aggressively with soap and water three times a day.
50. A patient is admitted with second- and third-degree burns covering the face, entire right upper
extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate
the extent of these burns as being?

A. 18%
B. 22.5%
C. 27%
D. 36%
51. A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse
would classify this burn as which of the following?
Select all that apply.
1. a superficial partial-thickness burn
2. a thermal burn
3. a superficial burn
4. a deep partial-thickness burn
5. a full-thickness burn
52. A patient is brought to the emergency department with the following burn injuries: a blistered and
reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent
of the burn injury (TBSA) using the rule of nines.
Correct Answer: 22.5
53. An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse
can give to the family to help prevent this patient from being accidently burned in her new home?

A. Cook for her.

B. Stop her from smoking.
 C. Install tap water anti-scald devices.
D. Be sure she uses an open space heater.
54.Pain management for the burn patient is most effective when (SATA):

a. a pain rating tool is used to monitor the patient's level of pain

b. painful dressing changes are delayed until the patient's pain is completely relieved
c. the patient is informed about and has some control over the management of the pain
d. a multi-modal approach is used (e.g., sustained-release and short-acting opioids, NSAIDS,
adjuvant analgesics).
e. non-pharmacological therapies (e.g., music therapy, distraction) replace opioids in the
rehabilitation phase of a burn injury
55. A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface
area involving both lower legs. The nurse would classify this injury as being which of the following?
1. a moderate burn
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn
56.The ambulance reports that they are transporting a patient to the ED who has experienced a full-
thickness thermal burn from a grill. What manifestations should the nurse expect?

A. Severe pain, blisters, and blanching with pressure

B. Pain, minimal edema, and blanching with pressure
C. Redness, evidence of inhalation injury, and charred skin
D. No pain, waxy white skin, and no blanching with pressure
57. A therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn
recover is:

a. applying pressure garments

b. repositioning the patient every 2 hours
c. performing active ROM at least every 4 hours
d. massaging the new tissue with water-based moisturizers
58. A patient is recovering from second- and third-degree burns over 30% of his body and is now ready
for discharge. The first action the nurse should take when meeting with the patient would be to:

a. arrange a return-to-clinic appointment and prescription for pain medications

b. teach the patient and caregiver proper wound care to be performed at home
c. review the patient's current health care status and readiness for discharge to home
d. give the patient written discharge information and websites for additional information for burn
survivors.\
59.In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the
emergent phase of burn injury when what happens?

A. Serum sodium and potassium increase

B. Serum sodium and potassium decrease.
C. Edema and arterial blood gases improve.
D. Diuresis occurs and hematocrit decreases.
60. A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-
thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury?
1. major
2. moderate
3. minor
4. superficial
5. Intermediate
61. A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is
MOST important to emphasize to an older adult in dealing with the effects of the sunburn?
1. increasing fluid intake
 2. applying mild lotions
3. taking mild analgesics
4. maintaining warmth
5. using sunscreen
62. When teaching the patient about the use of range-of-motion (ROM), what explanations should the
nurse give to the patient? Select all that apply.

A. The exercises are the only way to prevent contractures.

B. Active and passive ROM maintain function of body parts.
C. ROM will show the patient that movement is still possible.
D. Movement facilitates mobilization of leaked exudates back into the vascular bed.
E. Active and passive ROM can only be done while the dressings are being changed.
63. A patient is being discharged after treatment for a scald burn that caused a superficial burn over one
hand and a superficial partial-thickness burn on several fingers. What should be included in this
patient's discharge instructions?
(Select all that apply)
1. Report any fever to your healthcare provider.
2. Report development of purulent drainage to your healthcare provider.
3. Use only sterile dressings on the fingers.
4. Cleanse the areas every hour with alcohol to prevent infection.
5. Apply the topical antimicrobial agent as instructed.

64. During the care of the patient with a burn in the acute phase, which new interventions should the
nurse expect to do after the patient progressed from the emergent phase?

A. Begin IV fluid replacement.

B. Monitor for signs of complications.
C. Assess and manage pain and anxiety.
D. Discuss possible reconstructive surgery.
65. A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The
nurse notes edema at the burned areas. Which of the following best describes the underlying cause for
this assessment finding?
1. inability of the damaged capillaries to maintain fluids in the cell walls
2. reduced vascular permeability at the site of the burned area
3. decreased osmotic pressure in the burned tissue
4. increased fluids in the extracellular compartment
5. the IV fluid being administered too quickly
66. The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2
diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority
intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?

A. Replace the blood lost.

B. Maintain a neutral pH.
C. Maintain fluid balance.
D. Replace serum potassium.
67. A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the
most important adverse effect of this medication for the nurse to manage?

A. GI distress
B. Tachycardia
C. Restlessness
D. Hypokalemia
68. A patient receiving treatment for severe burns over more than half of his body has an indwelling
urinary catheter. When evaluating the patient's intake and output, which of the following should be
taken into consideration?
1. The amount of urine will be reduced in the first 24-48 hours, and will then increase.
 2. The amount of urine output will be greatest in the first 24 hours after the burn injury.
3. The amount of urine will be reduced during the first eight hours of the burn injury and will then
increase as the diuresis begins.
4. The amount of urine will be elevated due to the amount of intravenous fluids administered during
the initial phases of treatment.
5. The amount of urine is expected to be decreased for three to five days.

69. The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who
experienced a major burn event on 45% of the body 24 hours ago. Which of the following results
would the nurse expect to see?
(Select all that apply)
1. glomerular filtration rate (GFR) reduced
2. specific gravity elevated
3. creatinine clearance reduced
4. BUN reduced
5. uric acid decreased
70. The patient in the emergent phase of a burn injury is being treated for pain. What medication should
the nurse anticipate using for this patient?

A. SQ tetanus toxoid
B. IV morphine sulfate
C. IM hydromorphone (Dilaudid)
D. PO oxycodone and acetaminophen (Percocet)\
71. When evaluating the laboratory values of the burn-injured patient, which of the following can be
anticipated?
1. decreased hemoglobin and elevated hematocrit levels
2. elevated hemoglobin and elevated hematocrit levels
3. elevated hemoglobin and decreased hematocrit levels
4. decreased hemoglobin and decreased hematocrit levels
5. hemoglobin and hematocrit levels within normal ranges
72. The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse
include in the discharge teaching for this patient?

A. Sit or lay in the position of comfort.

B. Wear a pressure garment for 8 hours each day.
C. Refer the patient to a counselor for psychosocial support.
D. Use the sun to increase the skin color on the healed areas.
73. When caring for a patient with an electrical burn injury, which order from the health care provider
should the nurse question?

a. mannitol 75 gm IV
b. urine for myoglobulin
c. LR at 25 mL/h
d. sodium bicarbonate 24 mEq q.4h

74. When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse
assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the
findings?
1. These values are normal for the patient's post-burn injury condition.
2. The patient is demonstrating manifestations consistent with the onset of an infection.
3. The patient is demonstrating manifestations consistent with an electrolyte imbalance.
4. The patient is demonstrating manifestations consistent with renal failure.
5. The patient is demonstrating manifestations of fluid volume overload.
75. A patient is admitted with second- and third-degree burns covering the face, entire right upper
extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate
the extent of these burns as being?

a. 18%
b. 22.5%
c. 27%
d. 36%
76. A patient has experienced a burn injury. Which of the following interventions by the nurse is of the
highest priority at this time?
1. determination of the type of burn injury
2. determination of the types of home remedies attempted prior to the patient's coming to the
hospital
3. assessment of past medical history
4. determination of body weight
5. determination of nutritional status

77. A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements
should the nurse include when instructing the patient prior to the procedure?
1. "You will begin to perform exercises to promote flexibility and reduce contractures after five
days."
2. "You will need to report any itching, as it might signal infection."
3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection
and improve success of the procedure."
4. "The procedure will be performed in your room."
5. "You will need to be in protective isolation for several weeks after the graft is performed."
78. A patient recovering from a major burn injury is complaining of pain. Which of the following
medications will be most therapeutic to the patient?
1. morphine 4 mg IV every 5 minutes
2. morphine 10 mg IM ever 3-4 hours
3. meperidine 75 mg IM every 3-4 hours
4. meperidine 50 mg PO every 3-4 hours
5. fentanyl citrate (Duragesic) 75 mcg patch every 3 days
79. A patient with a burn injury is prescribed silver nitrate. Which of the following nursing interventions
should be included for the patient?
Standard Text: Select all that apply.
1. Monitor daily weight.
2. Monitor the serum sodium levels.
3. Prepare to change the dressings every two hours.
4. Report black skin discolorations.
5. Push fluid intake.
80.When teaching the patient about the use of range-of-motion (ROM), what explanations should the
nurse give to the patient? (select all that apply)?

a. the exercises are the only way to prevent contractures

b. active and passive ROM maintain function of body parts

c. ROM will show the patient that movement is still possible

d. movement facilitates mobilization of leaked exudates back into the vascular bed.

e. active and passive ROM can only be done while the dressings are being changed

81. The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the
following laboratory values is the best indicator of a need to adjust the nutritional program?
1. glycosuria
 2. creatine phosphokinase (CPK)
3. BUN levels
4. hemoglobin
5. serum sodium levels

82. During the acute phase of burn treatment, important goals of patient care include which of the
following?
Select all that apply.
1. providing for patient comfort
2. preventing infection
3. providing adequate nutrition for healing to occur
4. splinting, positioning, and exercising affected joints
5. assessing home maintenance management

83. A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of
the body. What IV solution will be started initially?
1. warmed lactated Ringer's solution
2. dextrose 5% with saline solution
3. dextrose 5% with water
4. normal saline solution
5. 0.45% saline solution

84. A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the
most important adverse effect of this medication for the nurse to manage?

a. GI distress
b. tachycardia
c. restlessness
d. hypokalemia

85. Using the modified Brooke formula, calculate the amount of intravenous solution that will be
administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg.
Correct Answer: 2080 mL
Rationale: The modified Brooke formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2
mL × 52 kg × 40 = 4160 mL. One-half is given over the first eight hours, or 2080 mL.

86. The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse
include in the discharge teaching for this patient?

a. sit or lay in the position of comfort

b. wear a pressure garment for 8 hours each day
c. refer the patient to a counselor for phychosocial support
d. use the sun to increase the skin color on the healed areas

87. The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the
patient's leg. What is the most appropriate response by the nurse to this family?
1. "The scabs are really old burned tissue and need to be removed to promote healing."
2. "I'll ask the doctor to come and talk with you about the treatment plan."
3. "The patient asked for the scabs to be removed."
4. "The scabs are removed to check for blood flow to the burned area."

88. A patient with third-degree burns is prescribed gastrointestinal medication. The primary action of
this drug is which of the following?
1. to prevent the onset of a Curling's ulcer
2. to treat a preexisting duodenal ulcer
3. to ensure adequate peristalsis
4. for the antiemetic

89. A patient is coming into the emergency department with third-degree burns over 25% of his body.
The nurse should prepare which of the following solutions for intravenous infusion for this patient?
1. warmed lactated Ringer's
 2. 5% dextrose in water
3. 5% dextrose in 0.45 normal saline
4. 5% dextrose in normal saline

90. The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum
potassium level. The nurse realizes that this finding is consistent with which of the following?
1. the resolution of burn shock
2. the onset of burn shock
3. the onset of renal failure
4. the onset of liver failure

91.A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating
facial and neck edema. The nurse realizes that this patient most likely
1. is developing a hypersensitivity to the medication.
2. is reacting positively to the medication.
3. needs an increase in dosage of the medication.
4. is not responding to the medication.

92. Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes
that this patient
1. will need to have the procedure repeated.
2. will no longer need this procedure.
3. will need to be premedicated prior to the next procedure.
4. should have an escharotomy instead.

93. The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm.
During wound care, the nurse applies Elase to the burned areas. Which of the following types
ofwound debridement is this nurse using?
1. enzymatic
2. mechanical
3. surgical
4. Topical

94. A patient with third-degree burns is being treated with high-volume intravenous fluids and has a
urine output of 40 cc per hour. The nurse realizes that this urine output
1. is normal for this patient.
2. provides evidence that the patient is dehydrated.
3. provides evidence that the patient is over-hydrated.
4. is indicative of pending renal failure.

95. A patient with third-degree burns to his right arm is scheduled for passive range of motion to the
extremity every two hours. Which of the following should the nurse do prior to this exercise session?
1. Medicate for pain.
2. Empty the patient's in-dwelling catheter collection bag.
3. Change the patient's bed linens.
4. Change the dressing on the burn.

96. A patient with third-degree burns to her face just learned that she will have extensive scarring once
the burn heals. Which of the following nursing diagnoses would be applicable to this patient at this
time?
1. Powerlessness
2. Potential for Infection
3. Fluid Volume Deficit
4. Risk for Ineffective Airway Clearance

97. A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse
realizes that this patient most likely has experienced which of the following?
1. first-degree burn
2. superficial second-degree burn
3. deep second-degree burn
4. third-degree burn
98.A female patient comes into the clinic complaining of nausea and vomiting after spending the
weekend at a seaside resort. Which of the following should be the most important assessment for the
nurse?
1. normal rest and sleep pattern
2. typical meal pattern
3. if the patient had to change time zones when traveling to the resort
4. if the patient has been sunburned

99. A patient comes into the physician's office after sustaining chemical burns to the left side of his face
and right wrist. The nurse realizes that this patient needs to be treated
1. in the outpatient ambulatory clinic.
2. in the emergency department.
3. in a burn center.
4. in the doctor's office and then at home.