1110 Questions

Burns
1. The adult client was burned as a result of an explosion. The burn initially affected
the clients entire face (anterior half of head) and upper half of the anterior torso,
and there were circumferential burns to the lower half of both arms. The clients
clothes caught on fire, and the client ran, causing subsequent burn injuries to the
posterior surface of the head and the upper half of the posterior torso. Using the
rule of nines, what would be the extent to the burn injury?
a. 18%
b. 24%
c. 36%
d. 48%
2. The nurse is preparing to care for a burn client scheduled for an escharotomy
procedure being performed for a third-degree circumferential arm burn. The
nurse understands that the anticipated therapeutic outcome of the escharotomy
is :
a. Return of distal pulses
b. Brisk bleeding from the site
c. Decreasing edema formation
d. Formation of granulation tissue
3. A client is undergoing fluid replacement after being burned on 20% of her body
12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mmHg,
a pulse rate of 110 beats/min, and a urine output of 20mL over the past hour.
The nurse reports the findings to the physician and anticipates what of the
following prescriptions?
a. Transfusing 1 unit of packed red blood cells
b. Administering a diuretic to increase urine output
c. Increasing the amount of intravenous (IV) lactated Ringers solution
administered per hour
d. Changing the IV lactated Ringers solution to one that contains dextrose in
water
4. When caring for a client with extensive burns, the nurse anticipates that pain
medication will be administered via which route?
a. Oral
b. Intravenous
c. Intramuscular
d. Subcutaneous
5. The nurse is caring for a client who sustained superficial partial-thickness burns
on the anterior lower legs and anterior thorax. Which of the following does the
nurse expect to not during the resuscitation/emergent phase of the burn injury?
a. Decreased heart rate
b. Increased urinary output
c. Increased blood pressure
d. Elevated hematocrit levels
6. The nurse is caring for a client who suffered an inhalation injury from a wood
stove. The carbon monoxide blood report reveals a level of 12%. Based on this
level, the nurse would anticipate which of the following signs in the client?
a. Coma
b. Flushing
c. Dizziness
d. Tachycardia

7. The client arrives at the emergency department following a burn injury that
occurred in the basement at home and an inhalation injury is suspected. Which of
the following would the nurse anticipate to be prescribed for the client?
a. 100% oxygen via an aerosol mask
b. Oxygen via nasal cannula at 15L/min
c. Oxygen via nasal cannula at 10L/min
d. 100% oxygen via a tight-fitting, non-rebreather face mask
8. The nurse is administering fluids intravenously as prescribed to a client who
sustained superficial partial-thickness burn injuries of the back and legs. In
evaluating the adequacy of fluid resuscitation, the nurse understands that which
of the following would provide the most reliable indicator for determining the
adequacy?
a. Vital signs
b. Urine output
c. Mental status
d. Peripheral pulses
9. The nurse manager is observing a new nursing graduate caring for a burn client
in protective isolation. The nurse manager intervenes if the new nursing graduate
planned to implement which incorrect component of protective isolation
technique?
a. Using sterile gloves and linens
b. Performing strict hand-washing technique
c. Wearing gloves and a gown only when giving direct care to the client
d. Wearing protective garb, including a mask, gloves, cap, shoe covers,
gowns, and plastic apron
10. The nurse is caring for a client following an autograph and grafting to a burn
wound on the right knee. Which of the following would the nurse anticipate to be
prescribed for the client?
a. Out of bed
b. Bathroom privileges
c. Immobilization of the affected leg
d. Placing the affected leg in a dependent position
11. You have just received a change of shift report for the burn unit. Which client
should you assess first?
a. A client with deep partial-thickness burns on both legs who is complaining
of severe and continuous leg pain
b. A client who has just arrived from the emergency departments with facial
burns sustained in a house fire
c. A client who has just been transferred from the postanesthesia care unit
after have skin grafts applied to the anterior chest
d. A client admitted 3 weeks ago with full-thickness leg and buttock burns
who has been waiting for 3 hours to receive discharge teaching
12. You are performing a sterile dressing change for a client with infected deep
partial-thickness burns of the chest and abdomen. List the steps of the care plan
in the order in which each should be accomplished.
a. Apply silver sulfadiazine (Silvadene) ointment
b. Obtain specimens for aerobic and anaerobic wound cultures
c. Administer morphine sulfate 10mg intravenously (IV)
d. Debride the wound of eschar using gauze sponges
e. Cover the wound with a sterile gauze dressing
13. You are the nurse manager in the burn unit. Which client is best to assign to an
RN who has floated from the oncology unit?

a. A 23 year old who has just been admitted with burn over 30% of the body
after a warehouse fire
b. A 36 year old who requires discharge teaching about nutrition and wound
care after having skin grafts
c. A 45 year old with infected partial-thickness back and chest burns who has
a dressing scheduled
d. A 57 year old with full thickness burns on both arms who needs assistance
in positioning hand splints
14. You have just received the change of shift report in the burn unit. Which client
requires the most immediate assessment or intervention?
a. A 22 year old admitted 4 days previously with facial burns due to a house
fire who has been crying since recent visitors left
b. A 34 year old who returned from skin-graft surgery 3 hours ago and is
complaining of level 8 pain (on a scale of 10)
c. A 45 year old with partial thickness leg burns who has a temperature of
102.6F and a blood pressure of 98/46 mmHg
d. A 57 year old who was admitted with electrical burn 24 hours ago and has
a blood potassium level of 5.1 mEq/L
15. These medications have been prescribed for a 10 year old with deep partial and
full-thickness burns. Which medication is most important to double-check with
another licensed nurse before administration?
a. Silver sulfadiazine (Silvadene) ointment
b. Famotidine (Pepcid) 20mg IV
c. Midazolam (Versed) 0.5mg PO
d. Multivitamin (Centrum Kids) 1 tab PO
16. A nurse is assessing the fluid status of a client with a second degree burn who
weighs 60kg. the client is 5 hours postburn. The nurse determines that the
clients fluid status is inadequate and immediately notifies a physician when the
client exhibits:
a. Blood pressure 92/60 mmHg and pulse rate 100 beats/min
b. Respiratory rate 18 breaths per minute and pulse rate 60 beats/min
c. Pulse rate 130 beats/min and urine output 25mL/hr
d. Pulse rate 106 beats/min and temperature 98.4F
17. In planning the care for a client recovering from second or third degree burns,
which psychosocial nursing diagnosis should have the highest priority?
a. Disturbed sensory perception
b. Disturbed thought processes
c. Disturbed body image
d. Disturbed personal identity
18. Which interventions should a nurse implement to assist a client with problems of
anxiety and confusion in the critical phases of burn injury? SELECT ALL THAT
APPLY
a. Repeat statements of orientation to person, place, and time with the client
b. Turn the client every 2 hours for reorientation
c. Place familiar objects brought from home nearby so the client can touch
them
d. Implement a schedule for regular sleep/wake cycles
e. Keep the door of the room closed so that distractions can be controlled
f. Encourage the client to write notes to family members
19. A nurse is caring for a client with a large, open sterna wound resulting from a
burn injury. The client is receiving enteral feeding. Oxepa (an anti-inflammatory,
pulmonary 1.5 Cal/mL formula), at 25mL/hr. Which abnormal laboratory value,

reported in the table below, indicates that the client is receiving inadequate
nutrition?
Serum Lab Test

Clients Value

Normal Values

Phosphorus

2.0

3.0-4.5 mg/dL

Platelets

110

150-400/mm

Pre-albumin

10

15-36 mg/dL

Potassium

3.1

3.5-5.0 mEq/L

a. Phosphorus
b. Platelets
c. Pre-albumin
d. Potassium
20. A nurse is assessing a client following a skin graft. The nurse should suspect
infection in the grafted wound when observing that the client has:
a. A white blood cell count of 9.9
b. Serosanguineous drainage
c. Elevated temperature
d. Decreased urine output
21. An adults shirt catches on fire and is now in flames. He panics and runs into his
neighbors yard. Which of the following interventions is appropriate? SELECT ALL
THAT APPY
a. Dousing the flames with water
b. Removing his burned clothing
c. Removing his jewelry
d. Rolling him on the ground
22. The nurse is caring for a man admitted with severe burns sustained when his
clothing caught fire while he was burning leaves. During the acute burn phase,
the nurse explains to the man that his nursing care plan is directed toward all of
the following except:
a. Strict aseptic technique
b. Proper alignment of all joints
c. Maintenance of fluid and electrolytes
d. Frequent and routine administration of narcotics
23. The nurse is planning care for an adult man who is admitted with severe flame
burns. Nursing care planning is based on the knowledge that the first 24-48 hours
post-burn are characterized by:
a. An increase in the total volume of intravascular plasma
b. Excessive renal perfusion with diuresis
c. Fluid shift from interstitial spaces to plasma
d. Fluid shift from plasma to interstitial spaces
24. The nurse is caring for an adult who was admitted following severe burns
sustained in a house fire. The nurse understands that an acceptable range for
hourly urine output during the first two days post-burn is:
a. 20mL
b. 30-50mL
c. 100-150mL
d. 150-200mL

25. A client with a skin graft has undergone a full-thickness skin graft from her right
upper thigh to her upper chest area. The most appropriate nursing action in
caring for her donor site is to :
a. Keep the fine mesh gauze dressing on her chest soaked with normal saline
b. Completely immobilize her right upper thigh area
c. Maintain the compression bandage on her right upper thigh for several
days
d. Remove the nylon fabric adhered to the donor site no later than two to
three days after grafting has taken place
26. A 78 year old man is admitted with severe flame burns resulting from smoking in
bed. The nurse can expect his room environment to include:
a. Strict isolation techniques and policies
b. A semi-private room
c. Liberal unrestricted visiting
d. Equipment shared between the client ant the other burn client in the unit
27. A 23 year old factory worker was burned severely in an industrial accident. He
has second degree burns on his right leg and arm and on his back. He has third
degree burns on his left arm. The triage nurse, using the rule of nines, estimates
the extent of the clients burns as ____%.
28. An adult was burned in a house fire 16 hours ago. She suffered second and third
degree burns over 65% of her body. She is receiving lactated Ringers at
200mL/hr. Which intervention is a priority at this time?
a. Monitoring hourly urine output
b. Assessing for signs and symptoms of infection
c. Performing range of motion q1-2 hours
d. Meeting the high caloric needs of the client
29. A nurse is providing care for a severely burned client during the shock phase of
the burn injury. Which assessment findings would indicate that the client is
receiving adequate fluid volume replacement?
a. Urine output of 20 mL/hr, CVP 3, weak pulses, K level of 5.3
b. Urine output of 50mL/hr, BP 100/60, oriented to person and place
c. Weak thread pulses, BP 70/40, pulse 130, Hct 52%
d. Restlessness, confusion, urine output 15mL/hr, rapidly increasing weight
30. A client with severe burns is receiving IV Zantac. Which statement best explains
the reason for administration of this medication in this situation?
a. The client was treated for gastritis several years ago
b. The medication will reduce hypoxemia in burn clients
c. The medication is an H receptor antagonist and will decrease acid
secretion
d. The medication will aid in removal of pulmonary secretions
31. An 18 year old was burned 6 weeks ago. She is now ready for discharge. Select
the statement best reflecting understanding of discharge care.
a. I will be so glad to get home so that I dont have to wear this pressure
thing anymore.
b. I will need to call my doctor if my temperature goes up or this burn area
starts draining and oozing.
c. I really need to stick to a low-calorie, low-protein diet.
d. To prevent that area of new skin from feeling so tight, I can rub ice and
baby oil on it.
32. A client has suffered a chemical burn. The best initial action is to:
a. Roll the client in a blanket
b. Secure lead-lined gloves and move the client away from the chemical

c. Flush the area with copious amounts of water or normal saline

d. If the chemical is an acid, neutralize with a base
33. A child is presenting with burn injuries. What should be the nurses priority during
the initial assessment?
a. Inspect location, extent, and shape of burn injuries
b. Assess the childs and familys concerns regarding the childs appearance
c. Assess for signs of smoke inhalation and burns to the face and neck
d. Assess for signs and symptoms of infection
34. A nurse is assessing a child who is presenting with burn injuries. Which injuries
would least likely trigger the need for further assessment or evaluation for the
potential of child abuse and mandatory reporting?
a. Rope burn with edema
b. Cigarette burns
c. Splash burns on the front torso, face, and neck
d. Scald burns of the feet and legs
35. A 4 year old girl has been hospitalized for moderate burns. A nurse plans care
based on the knowledge that the most developmentally appropriate response to
the injuries and resultant treatment for a child this age is likely to be:
a. Anger and hostility while trying to not appear young
b. Pushing boundaries to further autonomy
c. Wanting clear instructions regarding details of treatment
d. Believing that she is responsible for the bad things that are happening to
her
36. A nurse is reviewing orders received for a newly admitted child with second and
third-degree burns over 10% of the total body surface area (TBSA). The child
weighs 20kg. the nurse should seek further clarification from a physician when
the physicians order is:
a. Ringers lactate (RL) at 50mL per hour for the next 8 hours
b. Insert a urinary catheter
c. Elevate the extremities above the level of the heart
d. Morphine sulfate IV prn for pain control
37. A nurse is assessing a 16 year old adolescent in an emergency department who
has been admitted because of burns over 25% of the clients body. Upon initial
examination, the nurse makes several observations. Which observation should be
most concerning to the nurse?
a. Area on upper extremities are mottled
b. Areas on upper extremities are moist and red
c. Areas on lower extremities are waxy white
d. Red blistering on anterior lower extremities
38. A nurse is caring for a 7 year old client who has been hospitalized for several
days with severe burn injuries in the lower extremities. On initial examination,
the nurse makes the following assessments regarding the clients right leg: distal
pulses are weak, capillary refill is greater than 3 seconds, and the child reports
feelings of numbness and tingling in the leg. What should be the nurses
interpretation of this information?
a. This is to be expected during this phase of burn healing
b. This is an emergency situation and a health-care provider should be
notified
c. Comparative assessment of the extremity in 1 hour is necessary
d. Fluid has accumulated under the scab of the burn and is decreasing blood
flow to the area

39. A nurse is caring for a toddler with second and third degree burns over 20% of
the body 8 hours postinjury. The most critical nursing diagnosis for this patient is:
a. Impaired physical immobility
b. Imbalanced nutrition: less than body requirements
c. Risk for imbalanced body temperature
d. Deficient fluid volume