Chapter 25: Nursing Management: Burns

Chapter 25: Nursing Management: Burns

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that
the skin is red, swollen, and covered with large blisters. The patient states that they are
very painful. The nurse will document the injury as
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.
DIF: Cognitive Level: Comprehension REF: 475
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 56%, Hb 17.2 mg/dL (172
g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L).
Which action will the nurse anticipate taking?
a. Continue to monitor the laboratory results.
b. Increase the rate of the ordered IV solution.
c. Type and crossmatch for a blood transfusion.
d. Document the findings in the patient’s record.
ANS: B
The patient’s lab data show hemoconcentration, which may lead to a decrease in blood
flow to the microcirculation unless fluid intake is increased. Documentation and
continuing to monitor are inadequate responses to the data. Since the hematocrit and
hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be
needed after the emergent phase.
DIF: Cognitive Level: Application REF: 479-483 TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
3. A patient is admitted to the burn unit with 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. What is the best action for the nurse to take?
Test Bank 25-2
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 immediately be notified so that intubation can rapidly be done.
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: Application REF: 481-482
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, the nurse will
decrease the fluid infusion rate to
a. 350 mL/hour.
b. 523 mL/hour.
c. 938 mL/hour.
d. 1250 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. In this case, the patient should receive
half of the initial rate, or 938 mL/hr.
DIF: Cognitive Level: Application REF: 483
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity