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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? c. Assess mucous membranes. d. Measure hourly urine output.

a. Check skin turgor. b. Monitor daily weight. 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? Administer vitamins and minerals intravenously. Insert a feeding tube and initiate enteral feedings. Infuse total parenteral nutrition via a central catheter. Encourage an oral intake of at least 5000 kcal per day.

a. b. c. d.

ANS: B

Enteral feedings can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient’s caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients unless the gastrointestinal tract is not available for use. DIF: Cognitive Level: Apply (application) REF: 446 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. While the patient’s full-thickness burn wounds to the face are exposed, what nursing action

prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds. ANS: B

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation. DIF: Cognitive Level: Apply (application) REF: 440 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand.

The nurse should place the patient in which position? Place the right arm and hand flexed in a position of comfort. Elevate the right arm and hand on pillows and extend the fingers. Assist the patient to a supine position with a small pillow under the head. Position the patient in a side-lying position with rolled towel under the neck.

a. b. c. d.

ANS: B

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be maintained in an extended position in order to avoid contractures. DIF: Cognitive Level: Apply (application) REF: 441 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse

strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider.

c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes. ANS: B

The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient’s circulation. DIF: Cognitive Level: Apply (application) REF: 433 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5

days ago. Which nursing assessment would best evaluate the effectiveness of the drug? c. Stool occult blood d. Abdominal distention

a. Bowel sounds b. Stool frequency ANS: C

H2 blockers and proton pump inhibitors are given to prevent Curling’s ulcer in the patient who has sustained burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite. DIF: Cognitive Level: Apply (application) REF: 443 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 11. Which prescribed drug is best for the nurse to give before scheduled wound debridement on a

patient with partial-thickness burns? a. ketorolac b. lorazepam (Ativan)

c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

ANS: D

Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids. DIF: Cognitive Level: Analyze (analysis) REF: 445 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A young adult patient who is in the rehabilitation phase after having deep partial-thickness

face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving? a. “I’m glad the scars are only temporary.” b. “I will avoid using a pillow, so my neck will be OK.” c. “Do you think dark beige makeup will cover this scar?” d. “I don’t think my boyfriend will want to look at me now.” ANS: C

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

DIF: Cognitive Level: Apply (application) REF: 447 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 13. The nurse caring for a patient admitted with burns over 30% of the body surface assesses that

urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories. ANS: B

The patient’s urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient’s immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning. DIF: Cognitive Level: Understand (comprehension) REF: 442 TOP: Nursing Process: Application MSC: NCLEX: Physiological Integrity 14. A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of

burn treatment. Which snack would be best for the nurse to offer to this patient? c. Vanilla milkshake d. Whole grain bagel

a. Bananas b. Orange gelatin ANS: C

A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories. DIF: Cognitive Level: Analyze (analysis) REF: 446 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. A patient has just arrived in the emergency department after an electrical burn from exposure

to a high-voltage current. What is the priority nursing assessment? c. Extremity movement d. Pupil reaction to light

a. Oral temperature b. Peripheral pulses ANS: C

All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status. DIF: Cognitive Level: Analyze (analysis) REF: 431 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

16. An employee spills industrial acids on both arms and legs at work. What action should the

occupational health nurse take first? Remove nonadherent clothing and wristwatch. Apply an alkaline solution to the affected area. Place a cool compress on the area of exposure. Cover the affected area with dry, sterile dressings.

a. b. c. d.

ANS: A

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended. DIF: Cognitive Level: Apply (application) REF: 429 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. A patient who has burns on the arms, legs, and chest from a house fire has become agitated

and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation. ANS: D

Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient. DIF: Cognitive Level: Analyze (analysis) REF: 437 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. A patient arrives in the emergency department with facial and chest burns caused by a house

fire. Which action should the nurse take first? Auscultate the patient’s lung sounds. Determine the extent and depth of the burns. Give the prescribed hydromorphone (Dilaudid). Infuse the prescribed lactated Ringer’s solution.

a. b. c. d.

ANS: A

A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured. DIF: Cognitive Level: Analyze (analysis)

REF: 430

OBJ: Special Questions: Prioritization MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

19. A patient with extensive electrical burn injuries is admitted to the emergency department.

Which prescribed intervention should the nurse implement first? c. Check potassium level. d. Assess oral temperature.

a. Assess pain level. b. Place on heart monitor. ANS: B

After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important, but it will take time before the laboratory results are back. The first intervention is to place the patient on a heart monitor and assess for dysrhythmias so that they can be monitored and treated if necessary. DIF: Cognitive Level: Analyze (analysis) REF: 431 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. Eight hours after a thermal burn covering 50% of a patient’s total body surface area (TBSA),

the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108. ANS: B

The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase. DIF: Cognitive Level: Analyze (analysis) REF: 434 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 21. Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr ANS: B

This patient has evidence of lower airway injury and hypoxemia, and should be assessed immediately to determine the need for O2 or intubation (or both). The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications. DIF: Cognitive Level: Analyze (analysis)

REF: 437

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 22. Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse

(RN) who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial-thickness facial burns b. A patient who has just returned from having a cultured epithelial autograft to the

chest c. A patient who has a weight loss of 15% from admission and will have enteral feedings started d. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration ANS: C

An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral f...