LATEST UPDATED NUR 265 EXAM 3 - MED
SURG 2: BURNS, COMPLEX CARE | COMPLETE
EXAM WITH CORRECT ANSWERS AND
RATIONALES. A+ GUARANTEED SUCCESS
1. A nurse is caring for a client who sustained
partial-thickness (second-degree) burns on
30% of total body surface area (TBSA). Which
finding during the emergent (resuscitative)
phase requires immediate intervention?
A) Urinary output of 35 mL per hour
B) Serum potassium of 5.8 mEq/L
C) Blood pressure of 100/60 mm Hg
D) Heart rate of 110 beats per minute
Correct answer: B
Rationale: Hyperkalemia (serum potassium
above 5.0) is common in the emergent phase
due to cell lysis and can cause cardiac
dysrhythmias. Urinary output of 35 mL per hour
is adequate (target 30 to 50 mL per hour).
Hypotension and tachycardia are expected
due to fluid shifts.
,2. A nurse is calculating fluid resuscitation for
a client with burns on 40% TBSA. The client
weighs 70 kg. Using the Parkland formula (4
mL per kg per % TBSA), how much fluid should
the client receive in the first 8 hours?
A) 2,800 mL
B) 5,600 mL
C) 8,400 mL
D) 11,200 mL
Correct answer: B
Rationale: Parkland formula: 4 mL x weight (kg)
x % TBSA. 4 x 70 x 40 = 11,200 mL in 24 hours.
Half of this (5,600 mL) is given in the first 8
hours, and the remaining half is given over the
next 16 hours. 5,600 mL is the correct first 8-
hour volume.
3. A nurse is assessing a client with a full-
thickness (third-degree) burn on the right
forearm. Which finding is most characteristic
of a full-thickness burn?
A) Blisters and severe pain
B) Red, moist, and weeping wound
,C) Waxy white, leathery, or charred
appearance with no sensation
D) Hyperemic (red) with blanching on pressure
Correct answer: C
Rationale: Full-thickness burns appear waxy
white, leathery, or charred, and there is no
sensation due to destruction of nerve endings.
Blisters and severe pain are characteristic of
partial-thickness burns. Redness with
blanching is seen in superficial burns.
4. A nurse is caring for a client 48 hours after a
major burn injury. The nurse notes a decrease
in urinary output from 40 mL per hour to 15 mL
per hour. Which action should the nurse take
first?
A) Increase the intravenous fluid rate
B) Notify the healthcare provider
C) Assess the client's blood pressure and heart
rate
D) Check the urinary catheter for kinks
Correct answer: D
Rationale: The first action is to assess for
mechanical obstruction (kinked catheter,
, empty drainage bag). After ruling out
obstruction, the provider should be notified,
and the fluid rate may be increased. Assessing
vital signs is important but does not address
the cause.
5. A nurse is providing wound care for a client
with a deep partial-thickness burn. Which
topical antimicrobial is most commonly used
for burn wounds?
A) Silver sulfadiazine (Silvadene)
B) Bacitracin
C) Neomycin
D) Clotrimazole
Correct answer: A
Rationale: Silver sulfadiazine is a broad-
spectrum topical antimicrobial commonly used
for burn wounds to prevent infection.
Bacitracin and neomycin are used for minor
wounds. Clotrimazole is an antifungal.
6. A nurse is assessing a client in the acute
phase of burn recovery (48 to 72 hours post-
injury). Which finding indicates the client is at
SURG 2: BURNS, COMPLEX CARE | COMPLETE
EXAM WITH CORRECT ANSWERS AND
RATIONALES. A+ GUARANTEED SUCCESS
1. A nurse is caring for a client who sustained
partial-thickness (second-degree) burns on
30% of total body surface area (TBSA). Which
finding during the emergent (resuscitative)
phase requires immediate intervention?
A) Urinary output of 35 mL per hour
B) Serum potassium of 5.8 mEq/L
C) Blood pressure of 100/60 mm Hg
D) Heart rate of 110 beats per minute
Correct answer: B
Rationale: Hyperkalemia (serum potassium
above 5.0) is common in the emergent phase
due to cell lysis and can cause cardiac
dysrhythmias. Urinary output of 35 mL per hour
is adequate (target 30 to 50 mL per hour).
Hypotension and tachycardia are expected
due to fluid shifts.
,2. A nurse is calculating fluid resuscitation for
a client with burns on 40% TBSA. The client
weighs 70 kg. Using the Parkland formula (4
mL per kg per % TBSA), how much fluid should
the client receive in the first 8 hours?
A) 2,800 mL
B) 5,600 mL
C) 8,400 mL
D) 11,200 mL
Correct answer: B
Rationale: Parkland formula: 4 mL x weight (kg)
x % TBSA. 4 x 70 x 40 = 11,200 mL in 24 hours.
Half of this (5,600 mL) is given in the first 8
hours, and the remaining half is given over the
next 16 hours. 5,600 mL is the correct first 8-
hour volume.
3. A nurse is assessing a client with a full-
thickness (third-degree) burn on the right
forearm. Which finding is most characteristic
of a full-thickness burn?
A) Blisters and severe pain
B) Red, moist, and weeping wound
,C) Waxy white, leathery, or charred
appearance with no sensation
D) Hyperemic (red) with blanching on pressure
Correct answer: C
Rationale: Full-thickness burns appear waxy
white, leathery, or charred, and there is no
sensation due to destruction of nerve endings.
Blisters and severe pain are characteristic of
partial-thickness burns. Redness with
blanching is seen in superficial burns.
4. A nurse is caring for a client 48 hours after a
major burn injury. The nurse notes a decrease
in urinary output from 40 mL per hour to 15 mL
per hour. Which action should the nurse take
first?
A) Increase the intravenous fluid rate
B) Notify the healthcare provider
C) Assess the client's blood pressure and heart
rate
D) Check the urinary catheter for kinks
Correct answer: D
Rationale: The first action is to assess for
mechanical obstruction (kinked catheter,
, empty drainage bag). After ruling out
obstruction, the provider should be notified,
and the fluid rate may be increased. Assessing
vital signs is important but does not address
the cause.
5. A nurse is providing wound care for a client
with a deep partial-thickness burn. Which
topical antimicrobial is most commonly used
for burn wounds?
A) Silver sulfadiazine (Silvadene)
B) Bacitracin
C) Neomycin
D) Clotrimazole
Correct answer: A
Rationale: Silver sulfadiazine is a broad-
spectrum topical antimicrobial commonly used
for burn wounds to prevent infection.
Bacitracin and neomycin are used for minor
wounds. Clotrimazole is an antifungal.
6. A nurse is assessing a client in the acute
phase of burn recovery (48 to 72 hours post-
injury). Which finding indicates the client is at
