TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
Chapter 21: Burns m m
Test Bank MUL
m m
TIPLE CHOIC m
E
1. When assessing a patient who spilled hot oil on the right leg and foot, the
m m m m m m m m m m m m m m m
nurse notes that the skin is dry, pale, hard skin. The patient states that the
m m m m m m m m m m m m m m m
burn is not painful. What term would the nurse use to document the burn d
m m m m m m m m m m m m m m
epth?
a. First-degree skin destruction m m
b. Full-thickness skin destruction m m
c. Deep partial-thickness skin destruction
m m m
d. Superficial partial- m
thickness skin destruction ANS: B
m m m m
With full- m
thickness skin destruction, the appearance is pale and dry or leathery and th
m m m m m m m m m m m m
e area is painless because of the associated nerve destruction. Erythema, swe
m m m m m m m m m m m
lling, and blisters point to a deep partial-thickness burn.
m m m m m m m m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
,TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
With superficial partial-
m m
thickness burns, the area is red, but no blisters are present. First-
m m m m m m m m m m m
degree burns exhibit erythema, blanching, and pain.
m m m m m m
DIF: Cognitive Level: Understand (comprehension)
m m m m
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
m m m m m m m
2. On admission to the burn unit, a patient with an approximate 25% total
m m m m m m m m m m m m m
body surface area (TBSA) burn has the following initial laboratory results:
m m m m m m m m m m
m Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L),
m m m m m m m m
m
m m m m
and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse antici
m m
m
m m m m m m m m m
pate taking now?
m m
a. Monitor urine output every 4 hours.
m m m m m
b. Continue to monitor the laboratory results.
m m m m m
c. Increase the rate of the ordered IV solution.
m m m m m m m
d. Type and crossmatch for a blood transfusion.
m m m m m m
ANS: C m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
,TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
The patients laboratory data show hemoconcentration, which may lead to a
m m m m m m m m m m
m decrease in blood flow to the microcirculation unless fluid intake is increas
m m m m m m m m m m m
ed. Because the hematocrit and hemoglobin are elevated, a transfusion is in
m m m m m m m m m m m
appropriate, although transfusions may be needed after the emergent phase
m m m m m m m m m m
once the patients fluid balance has been restored. On admission to a burn u
m m m m m m m m m m m m m
nit, the urine output would be monitored more often than every 4 hours; lik
m m m m m m m m m m m m m
ely every1 hour.
m m
DIF: Cognitive Level: Apply (application)
m m m m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
, TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21-
m m m mm m
29) latest update m m
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
m m m m m m m
3. A patient is admitted to the burn unit with burns to the head, face, and h
m m m m m m m m m m m m m m m
ands. Initially, wheezes are heard, but an hour later, the lung sounds are d
m m m m m m m m m m m m m
ecreased and no wheezes are audible. What is the best action for the nurse
m m m m m m m m m m m m m
m to take?
m
a. Encourage the patient to cough and auscultate the lungs again.
m m m m m m m m m
b. Notify the health care provider and prepare for endotracheal intubati
m m m m m m m m m
on.
c. Document the results and continue to monitor the patients respiratory
m m m m m m m m m
rate.
m
d. Reposition the patient in high-
m m m m
Fowlers position and reassess breath sounds.
m m m m m
ANS: B m
The patients history and clinical manifestations suggest airway edema and the
m m m m m m m m m m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21-
m m m mm m
29) latest update m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
Chapter 21: Burns m m
Test Bank MUL
m m
TIPLE CHOIC m
E
1. When assessing a patient who spilled hot oil on the right leg and foot, the
m m m m m m m m m m m m m m m
nurse notes that the skin is dry, pale, hard skin. The patient states that the
m m m m m m m m m m m m m m m
burn is not painful. What term would the nurse use to document the burn d
m m m m m m m m m m m m m m
epth?
a. First-degree skin destruction m m
b. Full-thickness skin destruction m m
c. Deep partial-thickness skin destruction
m m m
d. Superficial partial- m
thickness skin destruction ANS: B
m m m m
With full- m
thickness skin destruction, the appearance is pale and dry or leathery and th
m m m m m m m m m m m m
e area is painless because of the associated nerve destruction. Erythema, swe
m m m m m m m m m m m
lling, and blisters point to a deep partial-thickness burn.
m m m m m m m m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
,TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
With superficial partial-
m m
thickness burns, the area is red, but no blisters are present. First-
m m m m m m m m m m m
degree burns exhibit erythema, blanching, and pain.
m m m m m m
DIF: Cognitive Level: Understand (comprehension)
m m m m
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
m m m m m m m
2. On admission to the burn unit, a patient with an approximate 25% total
m m m m m m m m m m m m m
body surface area (TBSA) burn has the following initial laboratory results:
m m m m m m m m m m
m Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L),
m m m m m m m m
m
m m m m
and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse antici
m m
m
m m m m m m m m m
pate taking now?
m m
a. Monitor urine output every 4 hours.
m m m m m
b. Continue to monitor the laboratory results.
m m m m m
c. Increase the rate of the ordered IV solution.
m m m m m m m
d. Type and crossmatch for a blood transfusion.
m m m m m m
ANS: C m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
,TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
The patients laboratory data show hemoconcentration, which may lead to a
m m m m m m m m m m
m decrease in blood flow to the microcirculation unless fluid intake is increas
m m m m m m m m m m m
ed. Because the hematocrit and hemoglobin are elevated, a transfusion is in
m m m m m m m m m m m
appropriate, although transfusions may be needed after the emergent phase
m m m m m m m m m m
once the patients fluid balance has been restored. On admission to a burn u
m m m m m m m m m m m m m
nit, the urine output would be monitored more often than every 4 hours; lik
m m m m m m m m m m m m m
ely every1 hour.
m m
DIF: Cognitive Level: Apply (application)
m m m m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1 m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21- m m m mm m
29) latest update m m
, TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21-
m m m mm m
29) latest update m m
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
m m m m m m m
3. A patient is admitted to the burn unit with burns to the head, face, and h
m m m m m m m m m m m m m m m
ands. Initially, wheezes are heard, but an hour later, the lung sounds are d
m m m m m m m m m m m m m
ecreased and no wheezes are audible. What is the best action for the nurse
m m m m m m m m m m m m m
m to take?
m
a. Encourage the patient to cough and auscultate the lungs again.
m m m m m m m m m
b. Notify the health care provider and prepare for endotracheal intubati
m m m m m m m m m
on.
c. Document the results and continue to monitor the patients respiratory
m m m m m m m m m
rate.
m
d. Reposition the patient in high-
m m m m
Fowlers position and reassess breath sounds.
m m m m m
ANS: B m
The patients history and clinical manifestations suggest airway edema and the
m m m m m m m m m m
TESTBANK FOR LEWIS MEDICAL SURGICAL NURSING 1
m m m m m m
1TH EDITION BYHARDING Questions & Answers satisfa
m m m mm m m m
ction guaranteed success ( CHAPTERS 21-
m m m mm m
29) latest update m m
