chapter 27

Question 1

The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that
the skin is red, swollen, and covered with large blisters. The client states that they are very
painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destruction
b. Deep full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction

Answer 1

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.

Question 2

The nurse is admitting a client to the burn unit who has an approximate 25% total body
surface area (TBSA) burn and the following initial laboratory results: Hct 56%, Hb 172
g/L, serum K+ 4.8 mmol/L, and serum Na+ 135 mmol/L. Which of the following actions
should the nurse anticipate implementing?
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 client’s record.

Answer 2

B
The client’s laboratory 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.

Question 3

The nurse is admitting a client to the burn unit who has 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. Which of the following actions should the nurse
implement first?
a. Encourage the client 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 client’s respiratory rate.
d. Reposition the client in high-Fowler’s position and reassess breath sounds.

Answer 3

B
The client’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
client in a more upright position or having the client cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because immediate action should
occur.

Question 4

The nurse is caring for a client with severe burns who is receiving crystalloid fluid
replacement IV, 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 1 875
mL/hour. Which of the following infusion rates is accurate after the first 8 hours?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1 250 mL/hour

Answer 4

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 (25% per each 8 hour period, respectively).
In this case, the client should receive half of the initial rate, or 938 mL/hour.

Question 5

The nurse is caring for a client who is in the emergent phase of burn care. Which of the
following nursing actions will be most useful in determining whether the client is
receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.

Answer 5

D
When fluid intake is adequate, the urine output will be at least 0.5–1 mL/kg/hour. The
client’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.

Question 6

The nurse is caring for a client who has just been admitted with a 40% total body surface
area (TBSA) burn injury. Which of the following interventions should the nurse include in
the plan of care to maintain adequate nutrition?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5 000 kcal/day.
d. Administer multiple vitamins and minerals in the IV solution.

Answer 6

A
Enteral feedings can usually be initiated during the emergent phase at low rates and
increased over 24–48 hours to the goal rate. During the emergent phase, the client 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 client’s caloric needs.
Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal
function, and is not routinely used in burn clients.

Question 7

The nurse is caring for a client who has deep partial-thickness and full-thickness burns of
the face and chest and is having the wounds treated with the open method. Which of the
following nursing actions should be included in the plan of care?
a. Restrict all visitors to prevent cross-contamination of wounds.
b. Wear gowns, caps, masks, and gloves during all care of the client.
c. Turn the room temperature up to at least 20°C (68°F) during dressing changes.
d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

Answer 7

B
Use of gowns, caps, masks, and gloves during all client care will decrease the possibility
of wound contamination for a client whose burns are not covered. Restricting all visitors is
not necessary and will have adverse psychosocial consequences for the client. The room
temperature should be kept at approximately 30°C (86°F) for clients with open burn
wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of
circulation.

Question 8

Which of the following actions should be included in the plan of care for a client who has
burns of the ears, head, neck, and right arm and hand?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the client to a supine position with a small pillow under the head.
d. Position the client in a side-lying position with rolled towel under the neck.

Answer 8

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
client). The client with burns of the ears should not use a pillow since this will put pressure
on the ears and may stick to the ears. Clients with neck burns should not use a pillow,
since the head should be maintained in an extended position in order to avoid contractures.

Question 9

The nurse is caring for a client who has circumferential burns of both arms and develops a
decrease in radial pulse strength and numbness in the fingers. Which of the following
actions should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both arms above heart level with pillows.
d. Encourage the client to flex and extend the fingers.

Answer 9

A
The decrease in pulse in a client with circumferential burns indicates decreased circulation
to the arms and the need for escharotomy. Monitoring the pulses is not an adequate
response to the decrease in circulation. Elevating the hands or increasing hand movement
will not improve the client’s circulation.

Question 10

The nurse is caring for a client who incurred extensive burn injuries 5 days ago and has
been prescribed ranitidine. Which of the following assessments should the nurse use to
evaluate the effectiveness of the medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood

Answer 10

D
H2 blockers are given to prevent Curling’s ulcer in the client who has suffered burn
injuries. H2 blockers do not impact bowel sounds, stool frequency, or appetite.

Question 11

The nurse is caring for a client who has partial-thickness burns. Which of the following
prescribed medications will be best for the nurse to use before wound debridement?
a. Ketorolac
b. Lorazepam
c. Gabapentin
d. Hydromorphone

Answer 11

D
Opioid pain medications are the best choice for pain control. The other medications are
used as adjuvants to enhance the effect of opioids.

Question 12

The nurse is caring for a client who is in the rehabilitation phase after having deep
partial-thickness face and neck burns and has a nursing diagnosis of disturbed body image.
Which of the following actions by the client indicates that the problem is resolving?
a. Stating that the scarring will only be temporary
b. Avoiding using a pillow to prevent neck contractures
c. Asking about how to use make-up to cover up the scars
d. Expressing sadness and anger about the scar appearance

Answer 12

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.

Question 13

The nurse is caring for a client who has burns over 30% of the body surface. Which of the
following events indicates that the client has moved from the emergent to the acute phase
of the burn injury?
a. White blood cell levels decrease.
b. Blisters and edema have subsided.
c. The client has large quantities of pale urine.
d. The client has been hospitalized for 48 hours.

Answer 13

C
At the end of the emergent phase, capillary permeability normalizes and the client 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 clients. Blisters and edema begin to resolve, but
this process requires more time. White blood cells may increase or decrease, based on the
client’s immune status and any infectious processes.

Question 14

Which of the following snacks will be best for the nurse to offer to a client with burns
covering 40% total body surface area (TBSA) who is in the acute phase of burn
treatment?
a. Strawberry gelatin
b. Whole wheat bagel
c. Chunky applesauce
d. Chocolate milkshake

Answer 14

D
A client with a burn injury needs high protein and calorie food intake, and the milkshake is
the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.

Question 15

Which of the following assessment parameters is the priority nursing assessment when
caring for a client who has just arrived in the emergency department after suffering an
electrical burn from exposure to a high-voltage current?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light

Answer 15

C
All clients with electrical burns should be considered at risk for cervical spine injury, and
assessments of extremity movement will provide baseline data. The other assessment data
also are necessary but not as essential as determining cervical spine status.

Question 16

The occupational health nurse is assessing an employee who has just spilled industrial
acids on the arms and legs. Which of the following actions is priority for the nurse to
implement?
a. Apply an alkaline solution to the affected area.
b. Place cool compresses on the area of exposure.
c. Cover the affected area with dry, sterile dressings.
d. Flush the burned area with large amounts of water.

Answer 16

D
With chemical burns, the initial action is to remove the chemical from contact with the
skin as quickly as possible. 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.

Question 17

The nurse is caring for a client who has burns on the back and chest from a house fire and
has become agitated and restless 9 hours after being admitted to the hospital. Which of the
following actions should the nurse take first?
a. Stay at the bedside and reassure the client.
b. Administer the ordered morphine sulphate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.

Answer 17

D
Agitation in a client who may have suffered inhalation injury might indicate hypoxemia,
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 also is appropriate but not as essential as determining
whether the client is hypoxemic. Reassurance is not helpful to reduce agitation in a
hypoxemic client.

Question 18

Which of the following actions should the nurse take first when a client arrives in the
emergency department with facial and chest burns caused by a house fire?
a. Infuse the ordered IV solution.
b. Auscultate the client’s lung sounds.
c. Determine the extent and depth of the burns.
d. Administer the ordered opioid pain medications.

Answer 18

B
A client 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.

Question 19

The nurse is admitting a client with extensive electrical burn injuries. Which of the
following prescribed interventions should the nurse implement first?
a. Start two large bore IVs.
b. Place on cardiac monitor.
c. Apply dressings to burned areas.
d. Assess for pain at contact points.

Answer 19

B
After an electrical burn, the client is at risk for fatal dysrhythmias and should be placed on
a cardiac monitor. The other actions should be accomplished in the following order: Start
two IVs, assess for pain, and apply dressings.

Question 20

Six hours after a thermal burn covering 50% of a client’s total body surface area (TBSA),
the nurse obtains these data when assessing a client. Which of the following information is
priority for the nurse to communicate to the health care provider?
a. Blood pressure is 94/46 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 104.
d. Urine output is 20 mL/hour for the past 2 hours.

Answer 20

D
The urine output should be at least 0.5–1.0 mL/kg/hour during the emergent phase, when
the client 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 systolic, and the pulse rate should be less than 120. Serous exudate from
the burns is expected during the emergent phase.

Question 21

After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. A client with 40% total body surface area (TBSA) burns who is receiving IV
fluids at 500 mL/hour
b. A client with smoke inhalation who has wheezes and altered mental status
c. A client with full-thickness leg burns who has a dressing change scheduled
d. A client with abdominal burns who is complaining of level 8 (0–10 scale) pain

Answer 21

B

This client has evidence of lower airway injury and hypoxemia and should be assessed
immediately to determine need for oxygen or intubation. The other clients also should be
assessed as rapidly as possible, but they do not have evidence of life-threatening
complications.

Question 22

Which of the following frequencies of multiple-dressing method burn treatment dressing
changes should the nurse should question?
a. Every 6 hours
b. Every 12 hours
c. Once a day
d. Once a week

Answer 22

A
These dressings are changed at various intervals, from every 12 to 24 hours to once every
14 days, depending on the product. However, the dressing should not be changed 6 hours
from application.

Question 23

The nurse notes a bright red skin colour for a client who was found unconscious from
smoke inhalation in a burning house. Which of the following actions should the nurse take
first?
a. Insert two large-bore IV lines.
b. Check the client’s orientation.
c. Place the client on 100% oxygen using a non-rebreather mask.
d. Assess for singed nasal hair and dark oral mucous membranes.

Answer 23

C
The client’s history and skin colour suggest carbon monoxide poisoning, which should be
treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions
to correct gas exchange.

Question 24

Which of the following laboratory results requires the most rapid action by the nurse who
is caring for a client who suffered a large burn 48 hours ago?
a. Hct 52%
b. BUN 13.8 mmol/L
c. Serum sodium 146 mmol/L
d. Serum potassium 6.2 mmol/L

Answer 24

D
Hyperkalemia can lead to fatal bradycardia and indicates that the client requires cardiac
monitoring and immediate treatment to lower the potassium level. The other laboratory
values also are abnormal and require changes in treatment, but they are not as immediately
life threatening as the elevated potassium level.

Question 25

The staff nurse is supervising a student nurse on the burn unit. Which of the following
actions by the student nurse require that the staff nurse intervene?
a. The student nurse uses clean latex gloves when applying antibacterial cream to a
burn wound.
b. The student nurse obtains burn cultures when the client has a temperature of
35.1°C (95.1°F).
c. The student nurse administers PRN fentanyl IV to a client 5 minutes before a
dressing change.
d. The student nurse calls the health care provider for an insulin order when a
nondiabetic client has an elevated serum glucose.

Answer 25

A
Sterile gloves should be worn when applying medications or dressings to a burn.
Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic
clients may require insulin because stress and high calorie intake may lead to temporary
hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just
before and during dressing changes for pain management.

Question 26

Which of the following nursing actions should be done first for a client who has suffered a
burn injury while working on an electrical power line?
a. Obtain the blood pressure.
b. Stabilize the cervical spine.
c. Assess for the contact points.
d. Check alertness and orientation.

Answer 26

B
Cervical spine injuries are commonly associated with electrical burns. Therefore
stabilization of the cervical spine takes precedence after airway management. The other
actions also are included in the emergent care after electrical burns, but the most important
action is to avoid spinal cord injury.