Chapter 24: Burns
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry,
pale, and 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
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: 432
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. 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 of
the following prescribed actions should be the nurse’s priority?
a.
Monitoring urine output every 4 hours.
b.
Continuing to monitor the laboratory results.
c.
Increasing the rate of the ordered IV solution.
d.
Typing and crossmatching for a blood transfusion.
ANS: C
The patient’s laboratory results 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 every1
hour).
DIF: Cognitive Level: Analyze (analysis) REF: 434
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. 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.
, 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: 434
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. 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.
219 mL/hr c. 938 mL/hr
b.
625 mL/hr d. 1875 mL/hr
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: 439
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. 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. c. Assess mucous membranes.
b.
Monitor daily weight. d. Measure hourly urine output.
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. 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: Analyze (analysis) REF: 434
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. 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.
Administer vitamins and minerals intravenously.
b.
Insert a feeding tube and initiate enteral feedings.
c.
Infuse total parenteral nutrition via a central catheter.
d.
Encourage an oral intake of at least 5000 kcal per day.
ANS: B
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry,
pale, and 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
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: 432
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. 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 of
the following prescribed actions should be the nurse’s priority?
a.
Monitoring urine output every 4 hours.
b.
Continuing to monitor the laboratory results.
c.
Increasing the rate of the ordered IV solution.
d.
Typing and crossmatching for a blood transfusion.
ANS: C
The patient’s laboratory results 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 every1
hour).
DIF: Cognitive Level: Analyze (analysis) REF: 434
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. 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.
, 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: 434
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. 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.
219 mL/hr c. 938 mL/hr
b.
625 mL/hr d. 1875 mL/hr
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: 439
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. 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. c. Assess mucous membranes.
b.
Monitor daily weight. d. Measure hourly urine output.
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. 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: Analyze (analysis) REF: 434
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. 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.
Administer vitamins and minerals intravenously.
b.
Insert a feeding tube and initiate enteral feedings.
c.
Infuse total parenteral nutrition via a central catheter.
d.
Encourage an oral intake of at least 5000 kcal per day.
ANS: B
