1. Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety?
a. Set hot water temperature at 140� F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit dr
C
2. The injury that is least likely to result in a full-thickness burn is
a. sunburn.
b. scald injury.
c. chemical burn.
d. electrical injury.
A
3. When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance.
A, D, E
4. A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and
D
5. Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. sequestering of sodium and water in interstitial fluid.
d.
C
6. To maintain a positive nitrogen balance in a major burn, the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about three times.
c. eat at least 1500 calories/day in small, frequent meals.
d. eat a gluten
A
7. A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to
a. reapply a new dressing without disturbing the wound bed.
b. obser
B
8. Pain management for the burn patient is most effective when (select all that apply)
a. a pain rating tool is used to monitor the patient's level of pain.
b. painful dressing changes are delayed until the patient's pain is completely relieved.
c. the pa
A, C, D
9. A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is
a. applying pressure garments.
b. repositioning the patient every 2 hours.
c. performing active ROM at least every 4 hours.
d. massaging the
A
10. A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to
a. arrange a return-to-clinic appointme
C
............
............
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 destructio
B
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).
C
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 p
B
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 hou
C
5. During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
a.
Check skin turgor.
c.
Assess mucous membranes.
b.
Monitor daily weight.
d.
Measure hourly urine out
D
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?
a.
Administer vitamins and minerals intravenously.
b.
Insert a feeding tube and initiate
B
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
B
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?
a.
Place the right arm and hand flexed in a position of comfort.
b.
Elevate the right arm and hand on p
B
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
B
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?
a.
Bowel sounds
c.
Stool occult blood
b.
Stool frequency
d.
Abdominal disten
C
11. Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns?
a.
ketorolac
c.
gabapentin (Neurontin)
b.
lorazepam (Ativan)
d.
hydromorphone (Dilaudid)
D
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
C
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.
Co
B
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?
a.
Bananas
c.
Vanilla milkshake
b.
Orange gelatin
d.
Whole grain bagel
C
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?
a.
Oral temperature
c.
Extremity movement
b.
Peripheral pulses
d.
Pupil reaction to light
C
16. An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first?
a.
Remove nonadherent clothing and wristwatch.
b.
Apply an alkaline solution to the affected area.
c.
Place a cool compress
A
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.
Adminis
D
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?
a.
Auscultate the patient's lung sounds.
b.
Determine the extent and depth of the burns.
c.
Give the prescribed
A
19. A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?
a.
Assess pain level.
c.
Check potassium level.
b.
Place on heart monitor.
d.
Assess oral temper
B
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.
Bloo
B
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 sche
B
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
C
23. A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?
a.
Insert two large-bore IV lines.
b.
Ch
D
24. The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?
a.
Hematocrit of 53%
c.
Serum potassium of 6.1 mEq/L
b.
Serum sodium of 147 mEq/L
d.
Blood urea nitrogen of 3
C
25. The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse?
a.
The new nurse uses clean gloves when applying antibacterial cream t
A
26. Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?
a.
Inspect the contact burns.
c.
Stabilize the cervical spine.
b.
Check the blood pressure.
d.
Assess alertness and orientation.
C
27. Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?
a.
Keep the right arm in a position of comfort.
b.
Avoid the use of sustained-release narcotics.
c.
Teach
D
28. A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best?
a.
"Most people recover aft
B
1. In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. Apply sterile gauze dressing.
b. Document wo
D, E, C, A, B