Chapter 25 Nursing Management Burns
Chapter 25: Nursing Management: Burns
Test Bank
MULTIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the
skin is dry, pale, 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: 454
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 action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
The patient’s laboratory data 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: Apply (application)
REF:
257
TOP: Nursing
Test Bank
MULTIPLE CHOICE
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the
skin is dry, pale, 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: 454
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 action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
The patient’s laboratory data 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: Apply (application)
REF:
257
TOP: Nursing