NURS 104 Exam 4 Questions With
Complete Verified Answers
\Q\.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 - ANSWERS✔-ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is
painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a
deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no
blisters are present. First-degree burns exhibit erythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension) REF: 454
\Q\.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. - ANSWERS✔-ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood
flow to the microcirculation unless fluid intake is increased. Because the hematocrit and
hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed
after the emergent phase once the patient's fluid balance has been restored. On admission to a
burn unit, the urine output would be monitored more often than every 4 hours; likely every 1
hour.
DIF: Cognitive Level: Apply (application) REF: 257
\Q\.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 - ANSWERS✔-ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and
the other half over the next 16 hours. In this case, the patient should receive half of the initial
rate, or 938 mL/hr.
DIF: Cognitive Level: Apply (application) REF: 460
,\Q\.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. - ANSWERS✔-
ANS: B
The patient's history and clinical manifestations suggest airway edema and the health care
provider should be notified immediately, so that intubation can be done rapidly. Placing the
patient in a more upright position or having the patient cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because immediate action should occur.
DIF: Cognitive Level: Apply (application) REF: 459
\Q\.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. - ANSWERS✔-ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The
patient's weight is not useful in this situation because of the effects of third spacing and
evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but
, they are not as adequate in determining that fluid infusions are maintaining adequate
perfusion.
DIF: Cognitive Level: Apply (application) REF: 460-461
\Q\.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. - ANSWERS✔-ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and increased
over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to
eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents
adequate nutrient absorption. Vitamins and minerals may be administered during the emergent
phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition
increases the infection risk, does not help preserve gastrointestinal function, and is not
routinely used in burn patients.
DIF: Cognitive Level: Apply (application) REF: 463
\Q\.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.
Complete Verified Answers
\Q\.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 - ANSWERS✔-ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is
painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a
deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no
blisters are present. First-degree burns exhibit erythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension) REF: 454
\Q\.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. - ANSWERS✔-ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood
flow to the microcirculation unless fluid intake is increased. Because the hematocrit and
hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed
after the emergent phase once the patient's fluid balance has been restored. On admission to a
burn unit, the urine output would be monitored more often than every 4 hours; likely every 1
hour.
DIF: Cognitive Level: Apply (application) REF: 257
\Q\.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 - ANSWERS✔-ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and
the other half over the next 16 hours. In this case, the patient should receive half of the initial
rate, or 938 mL/hr.
DIF: Cognitive Level: Apply (application) REF: 460
,\Q\.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. - ANSWERS✔-
ANS: B
The patient's history and clinical manifestations suggest airway edema and the health care
provider should be notified immediately, so that intubation can be done rapidly. Placing the
patient in a more upright position or having the patient cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because immediate action should occur.
DIF: Cognitive Level: Apply (application) REF: 459
\Q\.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. - ANSWERS✔-ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The
patient's weight is not useful in this situation because of the effects of third spacing and
evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but
, they are not as adequate in determining that fluid infusions are maintaining adequate
perfusion.
DIF: Cognitive Level: Apply (application) REF: 460-461
\Q\.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. - ANSWERS✔-ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and increased
over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to
eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents
adequate nutrient absorption. Vitamins and minerals may be administered during the emergent
phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition
increases the infection risk, does not help preserve gastrointestinal function, and is not
routinely used in burn patients.
DIF: Cognitive Level: Apply (application) REF: 463
\Q\.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.
