1. Three days ago the client received circumferential, partial, and full—thickness burns to 30%
total body surface area of the chest and abdomen. The nurse monitors the client for restricted
breathing due to Which physiological response?
A. Development of a layer of eschar
B. Loss of elastin and collagen in the tissues
C. Hypoxia and ischemia of the lungs’ alveoli
D. Fluid overload in the alveoli of the lungs
ANSWER: A
A. A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness
burns, which, when circumferential and when combined with increased fluid retention,
can restrict circulation and lung expansion.
B. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness
burns but would not be a source of constriction that would prevent lung expansion.
C. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however,
restricted breathing (a mechanical process) is more of a risk due to circumferential
eschar formation.
D. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is
combined with eschar formation.
2. After touching a hot oven grate, the client telephones the ED asking for advice for the
singed fingers. Which initial statement by the nurse is most appropriate?
A. “Wrap ice in a washcloth and put it on the burn area.”
B. “Come to the ED so a doctor can assess your fingers.”
C. “Run cool water over the burned area on your fingers.”
D. “Apply an antibiotic skin ointment to prevent infection.”
ANSWER: C
A. Ice causes vasoconstriction and can worsen the tissue damage.
B. The nurse should collect additional information before advising that the client be seen in
the ED. A first-degree bum ordinarily does not require medical care.
C. Cool water will minimize skin redness, pain, and swelling and limit tissue damage.
D. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an
, oily base, it can prevent healing.
3. The nurse determines that the fluid status of the client with a second-degree bum is
inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg.
Which findings prompted the nurse’s action?
A. Blood pressure 92/60 mm Hg and pulse 100 bpm
B. Respirations 18 per minute and pulse 60 bpm
C. Pulse 130 bpm and urine output 25 mL/hr
D. Pulse 106 bpm and temperature 98.4°F (369°C)
ANSWER: C
A. The MAP for a BP of 92/60 mm Hg is 707, indicating adequate perfusion (MAP =
[systolic BP + diastolic BP + diastolic BP] / 3; thus [92 + 60 + 60] / 3 = 70.7). A pulse of
100 bpm is WNL.
B. Respirations of 18 per minute and pulse of 60 bpm are both WNL.
C. The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132
lb, 21 pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs
of inadequate circulating fluid volume.
D. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (369°C)
is considered normal. These alone would not indicate inadequate fluids.
4. When assessing a burn victim’s skin the nurse notices the entire right and left upper
extremities are red, moist, weeping, and blistered. How should the nurse document the degree
and total body surface area (TBSA) burned?
A. First-degree burn on 9% TBSA
B. Partial—thickness burn on 18% TBSA
C. Partial-thickness burn on 27% TBSA
D. Full-thickness burn on 36% TBSA
ANSWER: B
A. This is not a first-degree burn- In a first-degree burn the skin may appear red but intact,
no weeping, and no blistering. In an adult, one upper extremity is approximately 9% of the
TB SA. However, in this example both upper extremities are burned, which equals 18%
TBSA.
B. Partial-thickness burns damage the dermis and epidermis, often resulting in loss of
, epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18%
of the TBSA has a partial-thickness burn (9% TBSA per each upper extremity).
C. With full-thickness burns there would be loss of tissue and a black or white
charred/waxy appearance to the remaining tissues. In addition, the % TBSA is too high
for a burn affecting only the upper extremities.
D. With full-thickness burns there would also be loss of tissue and a black or white
charred/waxy appearance. In addition, the % TBSA is too high for a burn affecting only
the upper extremities.
5. The nurse is planning the care for clients recovering from second- or third-degree burns.
Which psychosocial nursing problem should be priority?
A. Altered sensory perception
B. Altered skin integrity
C. Disturbed body image
D. Disturbed personal identity
ANSWER: C
A. Altered sensory perception is a physiological problem.
B. Altered skin integrity is a physiological problem.
C. Disturbed body image occurs during the recovering stages of the burn condition and
should be priority.
D. Disturbed personal identity is less likely to occur than disturbed body image.
6 . The nurse completes teaching the client with a second-degree burn about silver
sulfadiazine. Which client statements should indicate to the nurse that the teaching was
effective? Select all that apply.
A. “1 apply the cream only to the opened areas of the burned area.”
B. “Silver sulfadiazine will prevent an infection of the burned area.”
C. “I never should apply a dressing after applying silver sulfadiazine.”
D. “I use a tongue blade to remove the old ointment before reapplying.”
E. “The cream is dark colored and cannot be removed with water.”
ANSWER: A, B
total body surface area of the chest and abdomen. The nurse monitors the client for restricted
breathing due to Which physiological response?
A. Development of a layer of eschar
B. Loss of elastin and collagen in the tissues
C. Hypoxia and ischemia of the lungs’ alveoli
D. Fluid overload in the alveoli of the lungs
ANSWER: A
A. A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness
burns, which, when circumferential and when combined with increased fluid retention,
can restrict circulation and lung expansion.
B. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness
burns but would not be a source of constriction that would prevent lung expansion.
C. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however,
restricted breathing (a mechanical process) is more of a risk due to circumferential
eschar formation.
D. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is
combined with eschar formation.
2. After touching a hot oven grate, the client telephones the ED asking for advice for the
singed fingers. Which initial statement by the nurse is most appropriate?
A. “Wrap ice in a washcloth and put it on the burn area.”
B. “Come to the ED so a doctor can assess your fingers.”
C. “Run cool water over the burned area on your fingers.”
D. “Apply an antibiotic skin ointment to prevent infection.”
ANSWER: C
A. Ice causes vasoconstriction and can worsen the tissue damage.
B. The nurse should collect additional information before advising that the client be seen in
the ED. A first-degree bum ordinarily does not require medical care.
C. Cool water will minimize skin redness, pain, and swelling and limit tissue damage.
D. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an
, oily base, it can prevent healing.
3. The nurse determines that the fluid status of the client with a second-degree bum is
inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg.
Which findings prompted the nurse’s action?
A. Blood pressure 92/60 mm Hg and pulse 100 bpm
B. Respirations 18 per minute and pulse 60 bpm
C. Pulse 130 bpm and urine output 25 mL/hr
D. Pulse 106 bpm and temperature 98.4°F (369°C)
ANSWER: C
A. The MAP for a BP of 92/60 mm Hg is 707, indicating adequate perfusion (MAP =
[systolic BP + diastolic BP + diastolic BP] / 3; thus [92 + 60 + 60] / 3 = 70.7). A pulse of
100 bpm is WNL.
B. Respirations of 18 per minute and pulse of 60 bpm are both WNL.
C. The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132
lb, 21 pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs
of inadequate circulating fluid volume.
D. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (369°C)
is considered normal. These alone would not indicate inadequate fluids.
4. When assessing a burn victim’s skin the nurse notices the entire right and left upper
extremities are red, moist, weeping, and blistered. How should the nurse document the degree
and total body surface area (TBSA) burned?
A. First-degree burn on 9% TBSA
B. Partial—thickness burn on 18% TBSA
C. Partial-thickness burn on 27% TBSA
D. Full-thickness burn on 36% TBSA
ANSWER: B
A. This is not a first-degree burn- In a first-degree burn the skin may appear red but intact,
no weeping, and no blistering. In an adult, one upper extremity is approximately 9% of the
TB SA. However, in this example both upper extremities are burned, which equals 18%
TBSA.
B. Partial-thickness burns damage the dermis and epidermis, often resulting in loss of
, epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18%
of the TBSA has a partial-thickness burn (9% TBSA per each upper extremity).
C. With full-thickness burns there would be loss of tissue and a black or white
charred/waxy appearance to the remaining tissues. In addition, the % TBSA is too high
for a burn affecting only the upper extremities.
D. With full-thickness burns there would also be loss of tissue and a black or white
charred/waxy appearance. In addition, the % TBSA is too high for a burn affecting only
the upper extremities.
5. The nurse is planning the care for clients recovering from second- or third-degree burns.
Which psychosocial nursing problem should be priority?
A. Altered sensory perception
B. Altered skin integrity
C. Disturbed body image
D. Disturbed personal identity
ANSWER: C
A. Altered sensory perception is a physiological problem.
B. Altered skin integrity is a physiological problem.
C. Disturbed body image occurs during the recovering stages of the burn condition and
should be priority.
D. Disturbed personal identity is less likely to occur than disturbed body image.
6 . The nurse completes teaching the client with a second-degree burn about silver
sulfadiazine. Which client statements should indicate to the nurse that the teaching was
effective? Select all that apply.
A. “1 apply the cream only to the opened areas of the burned area.”
B. “Silver sulfadiazine will prevent an infection of the burned area.”
C. “I never should apply a dressing after applying silver sulfadiazine.”
D. “I use a tongue blade to remove the old ointment before reapplying.”
E. “The cream is dark colored and cannot be removed with water.”
ANSWER: A, B
