Lewis - Chapter 27: Nursing Management: Burns Exam Questions and Answers
With Verified Solutions 2025
The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that
the skin is red, swollen, and covered with large blisters. The client states that they are very
painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destruction
b. Deep full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - ✔✔ANS: C
The erythema, swelling, and blisters point to a deep partial-thickness burn. With
full-thickness skin destruction, the appearance is pale and dry or leathery and the area is
painless because of the associated nerve destruction. With superficial partial-thickness
burns, the area is red, but no blisters are present.
The nurse is admitting a client to the burn unit who has burns to the upper body and head
after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. Which of the following actions should the nurse
implement first?
a. Encourage the client 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 client's respiratory rate.
d. Reposition the client in high-Fowler's position and reassess breath sounds. - ✔✔ANS: B
The client's history and clinical manifestations suggest airway edema and the health care
provider should immediately be notified so that intubation can rapidly be done. Placing the
client in a more upright position or having the client cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because immediate action should
, occur.
The nurse is caring for a client with severe burns who is receiving crystalloid fluid
replacement IV, 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 1 875
mL/hour. Which of the following infusion rates is accurate after the first 8 hours?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1 250 mL/hour - ✔✔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 (25% per each 8 hour period, respectively).
In this case, the client should receive half of the initial rate, or 938 mL/hour.
The nurse is caring for a client who is in the emergent phase of burn care. Which of the
following nursing actions will be most useful in determining whether the client is receiving adequate
fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - ✔✔ANS: D
When fluid intake is adequate, the urine output will be at least 0.5-1 mL/kg/hour. The
client'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.
With Verified Solutions 2025
The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that
the skin is red, swollen, and covered with large blisters. The client states that they are very
painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destruction
b. Deep full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - ✔✔ANS: C
The erythema, swelling, and blisters point to a deep partial-thickness burn. With
full-thickness skin destruction, the appearance is pale and dry or leathery and the area is
painless because of the associated nerve destruction. With superficial partial-thickness
burns, the area is red, but no blisters are present.
The nurse is admitting a client to the burn unit who has burns to the upper body and head
after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. Which of the following actions should the nurse
implement first?
a. Encourage the client 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 client's respiratory rate.
d. Reposition the client in high-Fowler's position and reassess breath sounds. - ✔✔ANS: B
The client's history and clinical manifestations suggest airway edema and the health care
provider should immediately be notified so that intubation can rapidly be done. Placing the
client in a more upright position or having the client cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because immediate action should
, occur.
The nurse is caring for a client with severe burns who is receiving crystalloid fluid
replacement IV, 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 1 875
mL/hour. Which of the following infusion rates is accurate after the first 8 hours?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1 250 mL/hour - ✔✔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 (25% per each 8 hour period, respectively).
In this case, the client should receive half of the initial rate, or 938 mL/hour.
The nurse is caring for a client who is in the emergent phase of burn care. Which of the
following nursing actions will be most useful in determining whether the client is receiving adequate
fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - ✔✔ANS: D
When fluid intake is adequate, the urine output will be at least 0.5-1 mL/kg/hour. The
client'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.
