1. A client who has had a full-thickness burn is being discharged from the 12.

12. The client with a full-thickness burn is being discharged to home after a
hospital. Which information is most important for the nurse to provide month in the hospital. His wounds are minimally opened and he will be
prior to discharge? receiving home care. Which nursing diagnosis has the highest priority?
A. How to maintain home smoke detectors A. Acute Pain
B. Joining a community reintegration program B. Deficient Diversional Activity
C. Learning to perform dressing changes C. Impaired Adjustment
D. Options available for scar removal D. Imbalanced Nutrition: Less than Body Requirements
2. A client who is admitted after a thermal burn injury has the following 13. The client with a new burn injury asks the nurse why he is receiving
vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory intravenous cimetidine (Tagamet). What is the nurse’s best response?
rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which A. “Tagamet will stimulate intestinal movement.”
action will the nurse take first? B. “Tagamet can help prevent hypovolemic shock.”
A. Begin intravenous fluids. C. “This will help prevent stomach ulcers.”
B. Check the pulses with a Doppler device. D. “This drug will help prevent kidney damage.”
C. Obtain a complete blood count (CBC). 14. The client with facial burns asks the nurse if he will ever look the same.
D. Obtain an electrocardiogram (ECG). Which response is best for the nurse to provide?
3. A client who was burned has crackles and a respiratory rate of 40/min, A. “With reconstructive surgery, you can look the same.”
and is coughing up blood-tinged sputum. What action will the nurse take B. “We can remove the scars with the use of a pressure dressing.”
first? C. “You will not look exactly the same.”
A. Administer digoxin D. “You shouldn’t start worrying about your appearance right now.”
B. Perform chest physiotherapy 15. The client with open burn wounds begins to have diarrhea. The client is
C. Monitor urine output found to have a below-normal temperature, with a white blood cell count
D. Place the client in an upright position of 4000/mm3. Which is the nurse’s best action?
4. How will the nurse position a client with a burn wound to the posterior A. Continuing to monitor the client
neck to prevent contractures? B. Increasing the temperature in the room
A. Have the client turn the head from side to side. C. Increasing the rate of the intravenous fluids
B. Keep the client in a supine position without the use of pillows. D. Preparing to do a workup for sepsis
C. Keep the client in a semi-Fowler’s position with her or his arms elevated. 16. The family of a client who has been burned asks at what point the client
D. Place a towel roll under the client’s neck or shoulder. will no longer be at greater risk for infection. What is the nurse’s best
5. On assessment, the nurse notes that the client has burns inside response?
the mouth and is wheezing. Several hours later, the wheezing is no longer A. “As soon as he finishes his antibiotic prescription.”
heard. What is the nurse’s next action? B. “As soon as his albumin level returns to normal.”
A. Documenting the findings C. “When fluid remobilization has started.”
B. Loosening any dressings on the chest D. “When the burn wounds are closed.”
C. Raising the head of the bed 17. The nurse is conducting a home safety class. It is most important for the
D. Preparing for intubation nurse to include which information in the teaching plan?
6. Ten hours after the client with 50% burns is admitted, her A. Have chimneys swept every 2 years.
blood glucose level is 140 mg/dL. What is the nurse’s best action? B. Keep a smoke detector in each bedroom.
A. Documents the finding C. Use space heaters instead of gas heaters.
B. Obtains a family history of diabetes D. Use carbon monoxide detectors only in the garage.
C. Repeats the glucose measurement 18. The nurse provides wound care for a client 48 hours after a burn injury.
D. Stops IV fluids containing dextrose To achieve the desired outcome of the procedure, which nursing action will
7. The client has a large burned area on the right arm. The burned area be carried out first?
appears pink, has blisters, and is very painful. How will the nurse categorize A. Applies silver sulfadiazine (Silvadene) ointment
this injury? B. Covers the area with an elastic wrap
A. Full-thickness C. Places a synthetic dressing over the area
B. Partial-thickness superficial D. Removes loose nonviable tissue
C. Partial-thickness deep 19. The nurse should teach the community that a minor burn injury could
D. Superficial be caused by what common occurrence?
8. The client has burns on both legs. These areas appear white and leather- A. Chimney sweeping every year
like. No blisters or bleeding are present, and there is just a “small amount B. Cooking with a microwave oven
of pain.” How will the nurse categorize this injury? C. Use of sunscreen agents
A. Full-thickness D. Use of space heaters
B. Partial-thickness superficial 20. The nurse uses topical gentamicin sulfate (Garamycin) on a client’s burn
C. Partial-thickness deep injury. Which laboratory value will the nurse monitor?
D. Superficial A. Creatinine
9. The client has experienced an electrical injury of the lower extremities. B. Red blood cells
Which are the priority assessment data to obtain from this client? C. Sodium
A. Current range of motion in all extremities D. Magnesium level
B. Heart rate and rhythm
C. Respiratory rate and pulse oximetry reading
D. Orientation to time, place, and person 1. Answer: C. Learning to perform dressing changes
10. The client has severe burns around the right hip. Which position is most Critical for the goal of progression toward independence for the client is
important to use to maintain maximum function of this joint? teaching clients and family members to perform care tasks such as dressing
A. Hip maintained in 30-degree flexion changes. All the other distractors are important in the rehabilitation stage.
B. Hip at zero flexion with leg flat However, dressing changes have priority.
C. Knee flexed at 30-degree angle 2. Answer: A. Begin intravenous fluids.
D. Leg abducted with foam wedge Hypovolemic shock is a common cause of death in the emergent phase of
11. The client who is burned is drooling and having difficulty swallowing. clients with serious injuries. Fluids can treat this problem. An ECG and CBC
Which action will the nurse take first? will be taken to ascertain if a cardiac or bleeding problem is causing these
A. Assesses level of consciousness and pupillary reactions vital signs. However, these are not actions that the nurse would take
B. Ascertains the time food or liquid was last consumed immediately. Checking pulses would indicate perfusion to the periphery but
C. Auscultates breath sounds over the trachea and mainstem bronchi this is not an immediate nursing action.
D. Measures abdominal girth and auscultates bowel sounds 3. Answer: D. Place the client in an upright position
Pulmonary edema can result from fluid resuscitation given for burn
treatment. This can occur even in a young healthy person. Placing the client
in the upright position can relieve the lung congestion immediately before
other measures can be carried out. Digoxin may be given later to increase
cardiac contractility to prevent backup of fluid into the lungs. Chest
physiotherapy will not get rid of fluid. Monitoring urine output is important.
However, it is not an immediate intervention.
4. Answer: A. Have the client turn the head from side to side.
The function that would be disrupted by a contracture to the posterior neck
is flexion. Moving the head from side to side prevents such a loss of flexion.
The other distractors listed do not call for moving of the head from side to
side. This movement is what would prevent contractures from occurring.
5. Answer: D. Preparing for intubation
Clients with severe inhalation injuries may sustain such progressive
obstruction that they may lose effective movement of air. When this occurs,
wheezing is no longer heard and neither are breath sounds. The client
requires the establishment of an emergency airway. The swelling usually
precludes intubation.
6. Answer: A. Documents the finding
Neural and hormonal compensation to the stress of the burn injury in the
emergent phase increase liver glucose production and release. An acute rise
in the blood glucose level is an expected client response and is helpful in the
generation of energy needed for the increased metabolism that accompanies
this traumA. A family history of diabetes could make her more of a risk for
the disease, but this is not a priority at this time. The glucose level is not high
enough to warrant retesting. The cause of her elevated blood glucose is not
the IV fluid.
7. Answer: B. Partial-thickness superficial
The characteristics of the wound meet the criteria for a superficial partial-
thickness injury: color that is pink or red; blisters and pain present. Blisters
are not seen with full-thickness and superficial burns, and are rarely seen
with deep partial-thickness burns. Deep partial-thickness burns are red to
white in color.
8. Answer: A. Full-thickness
The characteristics of the wounds meet the criteria for a full-thickness injury:
color that is black, brown, yellow, white, or red; no blisters; pain minimal;
outer layer firm and inelastiC. Partial-thickness superficial burns appear pink
to red in color, with pain. Partial-thickness burn color is deep red to white in
color with pain, and superficial burn color is pink to red, with pain.
9. Answer: B. Heart rate and rhythm.
The airway is not at any particular risk with this injury. Therefore, respiratory
rate and pulse oximetry are not priority assessments. Electric current travels
through the body from the entrance site to the exit site and can seriously
damage all tissues between the two sites. Early cardiac damage from
electrical injury includes irregular heart rate, rhythm, and ECG changes.
Range of motion and neurologic assessments are important. However, the
priority is to make sure that the heart rate and rhythm are adequate to
support perfusion to the brain and other vital organs.
10. Answer: B. Hip at zero flexion with leg flat
Maximum function for ambulation occurs when the hip and leg are
maintained at full extension with neutral rotation. Although the client does
not have to spend 24 hours in this position, he or she should be in this
position (in bed or standing) longer than with the hip in any degree of flexion.
11. Answer: C. Auscultates breath sounds over the trachea and mainstem
bronchi
Inhalation injuries are present in 7% of clients admitted to burn centers.
Drooling and difficulty swallowing can mean that the client is about to lose
his airway because of this injury. The absence of breath sounds over the
trachea and mainstem bronchi indicates impending airway obstruction and
demands immediate intubation. Knowing the level of consciousness is
important to assess oxygenation to the brain. Ascertaining time of last food
intake is important in case intubation is necessary (the nurse would be more
alert for the signs of aspiration). However, assessing for air exchange is the
most important intervention at this time. Measuring abdominal girth is not
relevant in this situation.
12. Answer: C. Impaired Adjustment
Recovery from a burn injury requires a lot of work on the part of the client
and significant others. The client is seldom restored to his or her preburn
level of functioning. Adjustments to changes in appearance, family structure,
employment opportunities, role, and functional limitations are only a few of
the numerous life-changing alterations that must be made or overcome by
the client. By the rehabilitation phase, acute pain from the injury or its
treatment is no longer a problem.
13. Answer: C. “This will help prevent stomach ulcers.”
Ulcerative gastrointestinal disease may develop within 24 hours after a
severe burn as a result of increased hydrochloric acid production and
decreased mucosal barrier. This process occurs because of the
sympathetic nervous system stress response. Cimetidine inhibits the
production and release of hydrochloric acid. Cimetidine does not affect
intestinal movement, prevent hypovolemic shock, or prevent kidney damage.
14. Answer: C. “You will not look exactly the same.”
Many clients have unrealistic expectations of reconstructive surgery and
envision an appearance identical or equal in quality to the preburn state.
Pressure dressings prevent further scarring. They cannot remove scars. The
client and family should be taught the expected cosmetic outcomes.
15. Answer: D. Preparing to do a workup for sepsis
These findings are associated with systemic gram-negative infection and
sepsis. To verify that sepsis is occurring, cultures of the wound and blood
must be taken to determine the appropriate antibiotic to be started.
Continuing just to monitor the situation can lead to septic shock. Increasing
the temperature in the room may make the client more comfortable, but the
priority is finding out if the client has sepsis and treating it before it becomes
a shock situation. Increasing the rate of intravenous fluids may be done to
replace fluid losses with diarrhea, but is not the priority action.
16. Answer: D. “When the burn wounds are closed.”
Intact skin is a major barrier to infection and other disruptions
in homeostasis. No matter how much time has passed since the burn injury,
the client remains at high risk for infection as long as any area of skin is open.
17. Answer: B. Keep a smoke detector in each bedroom.
Everyone should use smoke detectors and carbon monoxide detectors in
their home environment (just not in a garage). Recommendations are that
each bedroom has a separate smoke detector. Space heaters can be a cause
of fire if clothing, bedding, and other flammable objects are nearby.
18. Answer: D. Removes loose nonviable tissue
All steps are part of the nonsurgical wound care for clients with burn injuries.
The first step in this process is removing exudates and necrotic tissue.
19. Answer: D. Use of space heaters
Minor burns are common occurrences. The use of space heaters can cause a
fire if clothing, bedding and other flammable objects are near them.
Chimneys should be swept each year to prevent creosote build-up and
resultant fire. Burn injuries do not commonly occur from microwave cooking,
but rather when taking food from this oven. Lastly, sunscreen agents are
recommended to prevent sunburn.
20. Answer: A. Creatinine
Gentamicin is nephrotoxic and sufficient amounts can be absorbed through
burn wounds to affect kidney function. Any client receiving gentamicin by
any route should have kidney function monitoreD. Topical gentamicin will
not affect the red blood cell count or sodium or magnesium level.
1. The RN has assigned a client who has an open burn wound to the LPN.
Which instruction is most important for the RN to provide the LPN?
A. Administer the prescribed tetanus toxoid vaccine.
B. Assess wounds for signs of infection.
C. Encourage the client to cough and breathe deeply.
D. Wash hands on entering the client’s room.
2. Three days after a burn injury, the client develops a temperature of 100°
F, white blood cell count of 15,000/mm3, and a white, foul-smelling
discharge from the wound. The nurse recognizes that the client is most
likely exhibiting symptoms of which condition?
A. Acute phase of the injury
B. Autodigestion of collagen
C. Granulation of burned tissue
D. Wound infection
3. Twelve hours after the client was initially burned, bowel sounds are
absent in all four abdominal quadrants. Which is the nurse’s best action?
A. Administers a laxative
B. Documents the finding
C. Increases the IV flow rate
D. Repositions the client onto the right side
4. What intervention will the nurse implement to reduce a client’s painafter
a burn injury?
A. Administering morphine 4 mg intravenously.
B. Administering hydromorphone (Dilaudid) 4 mg intramuscularly.
C. Applying ice to the burned area
D. Avoiding tactile stimulation
5. What statement indicates the client needs further education regarding
the skin grafting (allografting)?
A. “Because the graft is my own skin, there is no chance it won’t ‘take.'”
B. “For the first few days after surgery, the donor sites will be painful.”
C. “I will have some scarring in the area when the skin is removed for
grafting.”
D. “I am still at risk for infection after the procedure.”
6. When providing care for a client with an acute burn injury, which nursing
intervention is most important to prevent infection by autocontamination?
A. Avoiding sharing equipment such as blood pressure cuffs between clients
B. Changing gloves between wound care on different parts of the client’s
body
C. Using the closed method of burn wound management
D. Using proper and consistent handwashing
7. Which assessment finding assists the nurse in confirming inhalation
injury?
A. Brassy cough
B. Decreased blood pressure
C. Nausea
D. Headache
8. Which finding indicates that fluid resuscitation has been successful for a
client with a burn injury?
A. Hematocrit = 60%
B. Heart rate = 130 beats/min
C. Increased peripheral edema
D. Urine output = 50 mL/hr
9. Which finding indicates to the nurse that a client with a burn injury has a
positive perception of his appearance?
A. Allowing family members to change his dressings
B. Discussing future surgical reconstruction
C. Performing his own morning care
D. Wearing the pressure dressings as ordered
10. Which finding indicates to the nurse that the client understands the
psychosocial impact of his severe burn injury?
A. “It is normal to feel depressed.”
B. “I will be able to go back to work immediately.”
C. “I will not feel anger about my situation.”
D. “Once I get home, things will be normal.”
11. Which finding is characteristic during the emergent period after a deep
full thickness burn injury?
A. Blood pressure of 170/100 mm Hg
B. Foul-smelling discharge from wound
C. Pain at site of injury
D. Urine output of 10 mL/hr
12. Which is the priority nursing diagnosis during the first 24 hours for a
client with chemical burns to the legs and arms that are red in color,
edematous, and without pain?
A. Decreased Tissue Perfusion
B. Disturbed Body Image
C. Risk for Disuse Syndrome
D. Risk for Ineffective Breathing Pattern
13. Which laboratory result, obtained on a client 24 hours post-burn injury,
will the nurse report to the physician immediately?
A. Arterial pH, 7.32
B. Hematocrit, 52%
C. Serum potassium,7.5 mmol/L (mEq/L)
D. Serum sodium, 131 mmol/L (mEq/L)
14. Which nursing intervention is likely to be most helpful in providing
adequate nutrition while the client is recovering from a thermal burn
injury?
A. Allowing the client to eat whenever he or she wants
B. Beginning parenteral nutrition high in calories
C. Limiting calories to 3000 kcal/day
D. Providing a low-protein, high-fat diet
15. Which statement best exemplifies the client’s understanding of
rehabilitation after a full-thickness burn injury?
A. “I am fully recovered when all the wounds are closed.”
B. “I will eventually be able to perform all my former activities.”
C. “My goal is to achieve the highest level of functioning that I can.”
D. “There is never full recovery from a major burn injury.”
16. Which statement indicates that a client with facial burns understands
the need to wear a facial pressure garment?
A. “My facial scars should be less severe with the use of this mask.”
B. “The mask will help protect my skin from sun damage.”
C. “This treatment will help prevent infection.”
D. “Using this mask will prevent scars from being permanent.”
17. The client with a dressing covering the neck is experiencing some
respiratory difficulty. What is the nurse’s best first action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
18. During the acute phase, the nurse applied gentamicin sulfate
(topical antibiotic) to the burn before dressing the wound. The client has all
the following manifestations. Which manifestation indicates that the client
is having an adverse reaction to this topical agent?
A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level
19. Which intervention is most important to use to prevent infection by
autocontamination in the burned client during the acute phase of recovery?
A. Changing gloves between wound care on different parts of the client’s
body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.
20. The burned client relates the following history of previous health
problems. Which one should alert the nurse to the need for alteration of
the fluid resuscitation plan?
A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month
1. Answer: D. Wash hands on entering the client’s room.
Infection can occur when microorganisms from another person or the
environment are transferred to the client. Although all the interventions
listed can help reduce the risk for infection, hand washing is the most
effective technique for preventing infection transmission.
2. Answer: D. Wound infection
Color change, purulent, foul-smelling drainage, increased white blood cell
count, and fever could all indicate infection. These symptoms will not be seen
in the acute phase of the injury. Autodigestion of collagen and granulation of
tissue will not increase the body temperature or cause foul-smelling wound
discharge.
3. Answer: B. Documents the finding
Decreased or absent peristalsis is an expected response during the emergent
phase of burn injury as a result of neural and hormonal compensation to the
stress of injury. No currently accepted intervention changes this response. It
is not the highest priority of care at this time.
4. Answer: A. Administering morphine 4 mg intravenously.
Drug therapy for pain management requires opioid and nonopioid analgesics.
The IV route is used because of problems with
absorption from the muscle and stomach. Tactile stimulation can be used for
pain management. For the client to avoid shivering, the room must be kept
warm and heat should be applied.
5. Answer: A. “Because the graft is my own skin, there is no chance it won’t
‘take.'”
Factors other than tissue type, such as circulation and infection, influence
whether and how well a graft will work. The client should be prepared for the
possibility that not all grafting procedures will be successful. The donor sites
will be painful after the surgery, there can be scarring in the area where skin
is removed for grafting, and the client is still at risk for infection.
6. Answer: B. Changing gloves between wound care on different parts of
the client’s body.
Autocontamination is the transfer of microorganisms from one area to
another area of the same client’s body, causing infection of a previously
uninfected area. Although all techniques listed can help reduce the risk for
infection, only changing gloves between carrying out wound care on different
parts of the client’s body can prevent autocontamination.
7. Answer: A. Brassy cough
Brassy cough and wheezing are some signs seen with inhalation injury. All the
other symptoms are seen with carbon monoxide poisoning.
8. Answer: D. Urine output = 50 mL/hr
The fluid remobilization phase improves renal blood flow, increases diuresis,
and restores blood pressure and heart rate to more normal levels, as well as
laboratory values.
9. Answer: C. Performing his own morning care
Indicators that the client with a burn injury has a positive perception of his
appearance includes the willingness to touch the affected body part. Self-
care activities such as morning care foster feelings of self-worth, which are
closely linked to body image. Allowing others to change the dressing and
discussing future reconstruction would not indicate a positive perception of
appearance. Wearing the dressing will assist in decreasing complications, but
will not increase self-perception.
10. Answer: A. “It is normal to feel depressed.”
During the recovery period, and for some time after discharge from the
hospital, clients with severe burn injuries are likely to have psychological
problems that require intervention. Depression is one of these problems.
Feelings of grief, loss, anxiety, anger, fear, and guilt are all normal feelings
that can occur. Clients need to know that problems of physical care and
psychological stresses may be overwhelming.
11. Answer: D. Urine output of 10 mL/hr
During the fluid shift of the emergent period, blood flow to the kidney may
not be adequate for glomerular filtration. As a result, urine output is greatly
decreaseD. Foul-smelling discharge does not occur during the emergent
phase and blood pressure is usually low. Pain does not occur with deep full-
thickness burns.
12. Answer: A. Decreased Tissue Perfusion
During the emergent phase, fluid shifts into interstitial tissue in burned areas.
When the burn is circumferential on an extremity, the swelling can compress
blood vessels to such an extent that circulation is impaired distal to the
injury, causing decreased tissue perfusion and necessitating the intervention
of an escharotomy. Chemical burns do not cause inhalation injury and a
disrupted breathing pattern. Disturbed body image and disuse syndrome can
develop. However, these are not priority diagnoses at this time.
13. Answer: C. Serum potassium,7.5 mmol/L (mEq/L)
The serum potassium level is changed to the degree that serious life-
threatening responses could result. With such a rapid rise in the potassium
level, the client is at high risk for experiencing severe cardiac dysrhythmias
and death. All the other findings are abnormal, but not to the same degree of
severity, and would be expected in the emergent phase after a burn injury.
14. Answer: A. Allowing the client to eat whenever he or she wants.
Clients should request food whenever they think that they can eat, not just
according to the hospital’s standard meal schedule. The nurse needs to work
with a nutritionist to provide a high-calorie, high-protein diet to help with
wound healing. Clients who can eat solid foods should ingest as many
calories as possible. Parenteral nutrition may be given as a last resort
because it is invasive and can lead to infectious and metabolic complications.
15. Answer: C. “My goal is to achieve the highest level of functioning that I
can.”
Although a return to pre-burn functional levels is rarely possible, burned
clients are considered fully recovered or rehabilitated when they have
achieved their highest possible level of physical, social, and emotional
functioning. The technical rehabilitative phase of rehabilitation begins with
wound closure and ends when the client returns to her or his highest
possible level of functioning.
16. Answer: A. “My facial scars should be less severe with the use of this
mask.”
The purpose of wearing the pressure garment over burn injuries for up to 1
year is to prevent hypertrophic scarring and contractures from forming. Scars
will still be present. Although the mask does provide protection of sensitive,
newly healed skin and grafts from sun exposure, this is not the purpose for
wearing the mask. The pressure garment will not alter the risk for infection.
17. Answer: B. Loosen the dressing
Respiratory difficulty can arise from external pressure. The first action in this
situation would be to loosen the dressing and then reassess the client’s
respiratory status.
18. Answer: D. Increased serum creatinine level
Gentamicin does not stimulate pain in the wound. The small, pale pink
bumps in the wound bed are areas of re-epithelialization and not an adverse
reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed
through burn wounds to affect kidney function. Any client receiving
gentamicin by any route should have kidney function monitored.
19. Answer: A.Changing gloves between wound care on different parts of
the client’s body
Autocontamination is the transfer of microorganisms from one area to
another area of the same client’s body, causing infection of a previously
uninfected area. Although all techniques listed can help reduce the risk for
infection, only changing gloves between carrying out wound care on different
parts of the client’s body can prevent autocontamination.
20. Answer: C. Myocardial infarction 1 year ago.
It is likely the client has a diminished cardiac output as a result of the old MI
and would be at greater risk for the development of congestive heart
failureand pulmonary edema during fluid resuscitation.
1. Nurse Malcolm is performing a sterile dressing change on a client with a
superficial partial thickness burn on the shoulder and back. Arrange the
steps in the order in which each should be performed?
1. Cover the wound using a sterile gauze dressing.
2. Administer Tramadol (Tramal) 50 mg IV.
3. Debride the wound of eschar using gauze sponges.
4. Apply silver nitrate ointment.
5. Obtain sample for wound culture.
A. 2,5,4,3,1
B. 2,3,5,4,1
C. 5,2,3,1,4
D. 5,4,3,1,2
2. Which of the following medications given to a 12-year-old client for the
treatment of deep partial thickness burn is the most important to double
check with another licensed nurse before administering it?
A. Aloe Vera Relief Burn spray.
B. Silver Sulfadiazine ointment.
C. Omeprazole 20 mg slow IV push.
D. Amitriptyline (Elavil) 50 mg PO.
3. The nurse is administering fluids intravenously as ordered to a client who
acquired full-thickness burn injury on the abdomen. To determine the
sufficiency of fluid resuscitation, the nurse would monitor which of the
following that would provide the most reliable parameter for determining
the adequacy?
A. Level of consciousness.
B. Peripheral pulses.
C. Urine output.
D. Vital signs.
4. Nurse Rodrigo is receiving an endorsement from the burn unit. Which of
the following clients should he assess first?
A. A client who has just been transferred from the PACU after having
allograft.
B. A client admitted 1 week ago with a superficial-thickness burn on the
buttocks which has been waiting for 2 hours to receive discharge
instructions.
C. A client who has just arrived from the emergency department with
burns on the neck and chest.
D. A client with deep partial-thickness burns on both thighs who is
complaining of severe and continuous pain.
5. Which of the following route should the nurse expect the
pain medication to be given to a client who was admitted with extensive
burns?
A. Oral.
B. Intramuscular.
C. Subcutaneous.
D. Intravenous.
6. Nurse Cirie is caring for a client who suffered a smoke inhalation
injury. The carbon monoxide report reveals a level of 35%. Based on the
level, which of the following signs should the nurse expect in the client?
A. Seizure.
B. Confusion.
C. Flushing.
D. Coma.
7. A client is brought to the emergency unit with third-degree burns on the
posterior trunk, right arm, and left posterior leg. Using the Rule of Nines,
what is the total body surface area that has been burned?
A. 36%.
B. 54%.
C. 45%.
D. 27%.
8. A medicine student arrives at the emergency unit due to a burn injury
that occurred inside the laboratory and an inhalation injury is suspected.
Which of the following is the appropriate oxygen therapy for the client?
A. Oxygen via nasal cannula at 5 L/min.
B. Oxygen via a tight fitting, non-rebreather face mask at 100%
concentration.
C. Oxygen via nasal cannula at 10 L/min.
D. Oxygen via Venturi mask at 30% Fi02.
9. The nurse is handling a client who sustained electrical burn on the arm
and wrist and is scheduled for a fasciotomy. After the procedure, the nurse
should assess the affected extremity in which of the following EXCEPT?
A. Sensation.
B. Color.
C. Distal circulation.
D. All of the above.
10. The nurse is caring for a client with a burn wound on the left knee and
an autograft and skin grafting was performed. Which of the following
activity will be prescribed for the client post op?
A. Elevation and immobilization of the affected leg.
B. Placing the affected leg in a dependent position.
C. Dangling of legs.
D. Bathroom privileges.>
11. Nurse Troyzan has just received the change-of-shift report in the burn
unit. Which of the following client requires the most immediate care?
A. A 50-year-old who was admitted with electrical burns 24 hours ago and
has a serum potassium level of 5 mEq/L.
B. A 40-year-old with partial thickness leg burns which has a temperature of
101.9°F and a blood pressure of 89/42 mm Hg.
C. A 30-year-old who returned from debridement surgery 3 hours ago and is
complaining of pain (Pain scale of 7/10).
D. A 25-year-old admitted 4 days previously with facial burns due to a house
fire which has been crying since recent visitors left.
12. 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 note during the
resuscitation/emergent phase of the burn injury?
A. Increased blood pressure.
B. Increased hematocrit levels.
C. Decreased heart rate.
D. Increased urine output.
13. The nurse manager is observing a new nursing graduate caring for a
burned client in protective isolation. The nurse manager intervenes if the
new nursing graduate planned to implement which incorrect component of
protective isolation technique?
A. Performing strict handwashing techniques.
B. Wearing protective garb, including a mask, gloves, cap, shoe covers,
gowns, and a plastic apron.
C. Using sterile bed sheets and linens.
D. Wearing gloves and a gown only when giving direct care to the client.
14. A client is undergoing fluid replacement after being burned 20% of her
body 12 hours ago. The nursing assessment reveals a blood pressure of
90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of
25 ml over the past hour. The nurse reports the findings to the physician
and anticipates which of the following orders?
A. Increasing the amount of intravenous (IV) lactated Ringer’s solution
administered per hour.
B. Transfusing 1 unit of packed red blood cells.
C. Administering diuretic to increase urine output.
D. Changing the IV lactated Ringer’s solution into dextrose in water.
15. Nurse Kelsey is a nurse manager assigned in the burn unit. Which client
is best to assigned to an RN who has floated from the surgery unit?
A. A client with infected partial-thickness back and chest burns who has a
dressing scheduled.
B. A client who has just been admitted with burns over 30% of the body after
a warehouse fire.
C. A client with full-thickness burns on both arms who needs assistance
in positioning hand splints.
D. A client who requires discharge teaching about nutrition and wound care
after having skin grafts.
16. A client sustained burns on the back. These areas appear dry, blotchy
cherry red, blistering, doesn’t blanch, no capillary refill and reduced or
absent sensation. This type of burn depth is classified as?
A. Superficial partial-thickness burn.
B. Superficial dermal.
C. Deep partial-thickness burn.
D. Full-thickness burn.
17. Which of the following refers to a wound covering brought about by the
donated human cadaver skin provided by the skin bank?
A. Autograft.
B. Homograft.
C. Heterograft.
D. Xenograft.
18. A client is being discharged today after undergoing autografting. What
would the nurse include in the discharge instructions?
A. Refrain from using splints.
B. Avoid smoking.
C. Exposed the site to sunlight.
D. Encourage weight-bearing exercise.
19. A client is prescribed by the physician to undergo an escharotomy.
Which of the following statements made by the nurse is true regarding this
procedure?
A. “It is the surgical removal of a thin layer of the client’s own unburned
skin.”
B. “A lengthwise incision is made through the burn eschar to relieve
vasodilation.”
C. “It is performed at the bedside and without anesthesia.”
D. “It is the application of topical enzyme agents directly to the wound, and
these agents digest necrotic collagen tissue”.
20. Rehabilitation is the final phase of the burn care. Which of the following
are the goals during this phase? Select all that apply
A. Provide emotional support.
B. Prevent hypovolemic shock.
C. Promote wound healing and proper nutrition.
D. Fluid replacement.
E. Help the client in gaining optimal physical functioning.
1. Answer: B. 2, 3, 5, 4,1
A pain medication is administered prior the dressing change since the type of
burn will be painful during the procedure. Then the wound is debrided
before getting the sample for culture to prevent other bacteria that can
contaminate the actual wound. An antibacterial cream such as silver nitrate
is applied to the area to attain the maximum effect of the medication. Lastly,
cover the wound using a sterile dressing.
2. Answer: D. Amitriptyline (Elavil) 50 mg PO.
Amitriptyline (Elavil) is useful in the management of neuropathic pain
following burn injury and since it is an antidepressant if given with a child,
utmost precaution is given.
 Options A, B, and C: All health facility practice double checking of
medications prior administration, Of all the medications given,
Amitriptyline is the most important to double check with another
licensed nurse.
3. Answer: C. Urine output.
Of all the options, Urine output is the most reliable indicator for determining
the adequacy of fluid resuscitation.
4. Answer: C. A client who has just arrived from the emergency department
with burns on the neck and chest.
Burns of the neck and chest are associated with inflammation and swelling of
the airway. Hence this patient requires the most immediate attention.
5. Answer: C. Intravenous.
For clients with major burns, the intravascular route is the preferred choice
of medicine administration.
 Options A and B: An extensive burn injury causes damage to
the muscleand subcutaneous area.
 Option D: Due to the burn injury, the gastrointestinal tract will
have decreased perfusion hence relief of pain will not be
experienced.
6. Answer: B. Confusion.
Signs and Symptoms of carbon monoxide levels between 21-40% (moderate
poisoning) include hypotension, tachycardia, headache, drowsiness,
confusion, nausea, and vomiting.
 Options A and D: Carbon monoxide levels of 41% to 60% result
in seizureand coma.
  Option C: Carbon monoxide levels of 11% to 20% result in
flushing.
7. Answer: A. 36%.
Based on the rule of nines, with posterior trunk equals 18%, right arm equals
9%, and left posterior leg equals 9%. Therefore, a total of 36%.
8. Answer: B. Oxygen via a tight fitting, non-rebreather face mask at 100%
concentration.
If an inhalation injury is suspected, management includes the administration
of oxygen via a tight fitting, non-rebreather face mask at 100%
concentration. This is prescribed until carboxyhemoglobin levels in the blood
fall below 15%.
9. Answer: D. All of the above.
Following fasciotomy, the nurse should assess pulses, color, sensation, and
movement of the affected extremity as well as bleeding.
10. Answer: A. Elevation and immobilization of the affected leg.
Autograft placed on the lower extremity requires elevation and
immobilization for at least 3-7days. This period of immobilization allows the
autograft time to adhere to the wound bed.
11. Answer: B. A 40-year-old with partial thickness leg burns which has a
temperature of 101.9°F and a blood pressure of 89/48 mm Hg.
The client’s vital signs indicate that life-threatening complications
of sepsismay be developing.
12. Answer: B. Increased hematocrit levels.
The resuscitation/emergent phase begins at the time of injury and ends with
the restoration of capillary permeability, usually at 48-72 hours following the
injury. During this phase, there is an elevation of the hematocrit levels due to
hemoconcentration from the large fluid shifts
 Option A: Blood pressure is decreased due to the shifting of fluids.
 Option C: Pulse rate is higher than normal.
 Option D: Initially, blood is shunted away from the kidneys,
resulting in low urine output.
13. Answer: D. Wearing gloves and a gown only when giving direct care to
the client.
 Option A: Thorough handwashing is performed before and after
each contact with the burn-injured client.
 Option B: Protective garbs such as mask, gloves, cap, shoe covers,
gowns, and a plastic apron need to be worn when having a direct
contact with the client.
 Option C: Sterile sheets and linen are used due to the high risk for
infection.
14. Answer: A. Increasing the amount of intravenous (IV) lactated Ringer’s
solution administered per hour.
The client’s urine output indicates inadequate fluid resuscitation. Hence the
physician would order an increase amount of lactated Ringer’s solution
administered hourly.
 Option B: Blood transfusion is not used for fluid resuscitation
therapy unless there is an indication of a low hemoglobin level.
 Option C: Diuretic works by removing circulating volume, thereby
further compromising the inadequate tissue perfusion.
 Option D: Dextrose in water will only maintain fluid balance since
it is an isotonic solution, therefore will not be helpful in this
situation.
15. Answer: A. A client with infected partial-thickness back and chest burns
who has a dressing scheduled.
Familiarity with the dressing change and practice of sterility by a nurse from
the surgery unit will be appropriately used during the float in the burn unit.
 Options B, C, and D: Admission assessment, splinting and
discharge teaching require expertise in caring for burn patients.
16. Answer: C. Deep partial-thickness burn.
Deep partial-thickness burn: blistering, dry, blotchy cherry red, doesn’t
blanch, no capillary refill and reduced or absent sensation. Generally, heals in
3-6 weeks, but scar formation results and skin grafting may be required.
 Option A: Superficial partial-thickness: red, glistening, pain,
absence of blisters and brisk capillary refill. Not life-threatening
and normally heal within a week, without scarring.
 Option B: pale pink or mottled appearance with associated
swelling and small blisters. With a wet, shiny, and weeping surface
is also a characteristic. Brisk capillary refill.
 Option D: Full-thickness: dry, white or black, no blisters, absent
capillary refill and absent sensation. Requires surgical repair and
grafting.
17. Answer: B. Homograft.
 Option A: Autograft: Skin taken from a remote unburned area of
client’s own body.
 Options C and D: Xenograft or Heterograft: graft of tissue taken
from a donor of one species and grafted into a recipient of
another species.
18. Answer: B. Avoid smoking.
Avoiding smoking since it can decrease the blood supply to the newly graft
recipient bed interface, and the chance of graft failure increases.
 Option A: The aPTT determines the effects of heparin therapy.
19. Answer: C. “It is performed at the bedside and without anesthesia”.
Escharotomy is performed at the bedside and without anesthesia since nerve
endings have been destroyed by the burn injury.
 Option A refers to skin autograft.
 Option B Escharotomy involves making a lengthwise incision
through the burn eschar to relieve vasoconstriction.
 Option D refers to enzymatic debridement.
20. Answer: A. Provide emotional support., C. Promote wound healing and
proper nutrition., E. Help the client in gaining optimal physical functioning.,
 Options B and D belongs to the main goal during the resuscitative
phase.
1. The newly admitted client has burns on both legs. The burned areas
appear white and leather-like. No blisters or bleeding are present, and the
client states that he or she has little pain. How should this injury be
categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
2. The newly admitted client has a large burned area on the right arm. The
burned area appears red, has blisters, and is very painful. How should this
injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
3. The burned client newly arrived from an accident scene is prescribed to
receive 4 mg of morphine sulfate by IV push. What is the most important
reason to administer the opioid analgesic to this client by the intravenous
route?
A. The medication will be effective more quickly than if given intramuscularly.
B. It is less likely to interfere with the client’s breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.
4. Which vitamin deficiency is most likely to be a long-term consequence of
a full-thickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
5. Which client factors should alert the nurse to potential increased
complications with a burn injury?
A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.
6. The burned client is ordered to receive intravenous cimetidine, an H2
histamine blocking agent, during the emergent phase. When the client’s
family asks why this drug is being given, what is the nurse’s best response?
A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent
ulcers.”
D. “To inhibit loss of fluid from the circulatory system and
prevent hypovolemic shock.”
7. At what point after a burn injury should the nurse be most alert for the
complication of hypokalemia?
A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase
8. What clinical manifestation should alert the nurse to possible carbon
monoxide poisoning in a client who experienced a burn injury during a
house fire?
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
9. What clinical manifestation indicates that an escharotomy is needed on a
circumferential extremity burn?
A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the
extremity.
10. What additional laboratory test should be performed on any African
American client who sustains a serious burn injury?
A. Total protein
B. Tissue type antigens
C. Prostate-specific antigen
D. Hemoglobin S electrophoresis
11. Which type of fluid should the nurse expect to prepare and administer
as fluid resuscitation during the emergent phase of burn recovery?
A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells
12. The client with a dressing covering the neck is experiencing some
respiratory difficulty. What is the nurse’s best first action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
13. The client who experienced an inhalation injury 6 hours ago has been
wheezing. When the client is assessed, wheezes are no longer heard. What
is the nurse’s best action?
A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.
14. Ten hours after the client with 50% burns is admitted, her
blood glucose level is 90 mg/dL. What is the nurse’s best action?
A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.
15. On admission to the emergency department the burned client’s blood
pressure is 90/60, with an apical pulse rate of 122. These findings are an
expected result of what thermal injury–related response?
A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning
16. Twelve hours after the client was initially burned, bowel sounds are
absent in all four abdominal quadrants. What is the nurse’s best action?
A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.
17. Which clinical manifestation indicates that the burned client is moving
into the fluid remobilization phase of recovery?
A. Increased urine output, decreased urine specific gravity
B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit
18. What is the priority nursing diagnosis during the first 24 hours for a
client with full-thickness chemical burns on the anterior neck, chest, and all
surfaces of the left arm?
A. Risk for Ineffective Breathing Pattern
B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image
19. All of the following laboratory test results on a burned client’s blood are
present during the emergent phase. Which result should the nurse report
to the physician immediately?
A. Serum sodium elevated to 131 mmol/L (mEq/L)
B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%
20. The client has experienced an electrical injury, with the entrance site on
the left hand and the exit site on the left foot. What are the priority
assessment data to obtain from this client on admission?
A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities
21. In assessing the client’s potential for an inhalation injury as a result of a
flame burn, what is the most important question to ask the client on
admission?
A. “Are you a smoker?”
B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”
22. Which information obtained by assessment ensures that the client’s
respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited
23. Which information obtained by assessment ensures that the client’s
respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited
24. The burned client’s family ask at what point the client will no longer be
at increased risk for infection. What is the nurse’s best response?
A. “When fluid remobilization has started.”
B. “When the burn wounds are closed.”
C. “When IV fluids are discontinued.”
D. “When body weight is normal.”
25. The burned client relates the following history of previous health
problems. Which one should alert the nurse to the need for alteration of
the fluid resuscitation plan?
A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month
26. The burned client on admission is drooling and having difficulty
swallowing. What is the nurse’s best first action?
A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four
quadrants.
27. Which intervention is most important for the nurse to use to prevent
infection by cross-contamination in the client who has open burn wounds?
A. Handwashing on entering the client’s room
B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas
28. In reviewing the burned client’s laboratory report of white blood cell
count with differential, all the following results are listed. Which laboratory
finding indicates the possibility of sepsis?
A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 1,800/mm3.
29. The client has a deep partial-thickness injury to the posterior neck.
Which intervention is most important to use during the acute phase to
prevent contractures associated with this injury?
A. Place a towel roll under the client’s neck or shoulder.
B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour
while awake.
D. Keep the client in a semi-Fowler’s position and actively raise the arms
above the head every hour while awake.
30. The client has severe burns around the right hip. Which position is most
important to be emphasized by the nurse that the client maintains to retain
maximum function of this joint?
A. Hip maintained in 30-degree flexion, no knee flexion
B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat
31. During the acute phase, the nurse applied gentamicin sulfate
(topical antibiotic) to the burn before dressing the wound. The client has all
the following manifestations. Which manifestation indicates that the client
is having an adverse reaction to this topical agent?
A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level
32. The client, who is 2 weeks postburn with a 40% deep partial-thickness
injury, still has open wounds. On taking the morning vital signs, the client is
found to have a below-normal temperature, is hypotensive, and
has diarrhea. What is the nurse’s best action?
A. Nothing, because the findings are normal for clients during the acute
phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.
33. Which intervention is most important to use to prevent infection by
autocontamination in the burned client during the acute phase of recovery?
A. Changing gloves between wound care on different parts of the client’s
body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.
34. When should ambulation be initiated in the client who has sustained a
major burn?
A. When all full-thickness areas have been closed with skin grafts
B. When the client’s temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift
35. What statement by the client indicates the need for further discussion
regarding the outcome of skin grafting (allografting) procedures?
A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
C. “I will have some scarring in the area when the skin is removed for
grafting.”
D. “Once all grafting is completed, my risk for infection is the same as it was
before I was burned.”
36. Which statement by the client indicates a correct understanding of
rehabilitation after burn injury?
A. “I will never be fully recovered from the burn.”
B. “I am considered fully recovered when all the wounds are closed.”
C. “I will be fully recovered when I am able to perform all the activities I did
before my injury.”
D. “I will be fully recovered when I achieve the highest possible level of
functioning that I can.”
37. Which statement made by the client with facial burns who has been
prescribed to wear a facial mask pressure garment indicates a correct
understanding of the purpose of this treatment?
A. “After this treatment, my ears will not stick out.”
B. “The mask will help protect my skin from sun damage.”
C. “Using this mask will prevent scars from being permanent.”
D. “My facial scars should be less severe with the use of this mask.”
38. What is the priority nursing diagnosis for a client in the rehabilitative
phase of recovery from a burn injury?
A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements
39. Nurse Faith should recognize that fluid shift in an client with burn injury
results from increase in the:
A. Total volume of circulating whole blood
B. Total volume of intravascular plasma
C. Permeability of capillary walls
D. Permeability of kidney tubules
40. Louie, with burns over 35% of the body, complains of chilling. In
promoting the client’s comfort, the nurse should:
A. Maintain room humidity below 40%
B. Place top sheet on the client
C. Limit the occurrence of drafts
D. Keep room temperature at 80 degrees
1. Answer: D. Full thickness
 Option D: The characteristics of the wound meet the criteria for a
full-thickness injury (color that is black, brown, yellow, white or
red; no blisters; pain minimal; outer layer firm and inelastic).
2. Answer: B. Partial-thickness superficial
 Option B: The characteristics of the wound meet the criteria for a
superficial partial-thickness injury (color that is pink or red;
blisters; pain present and high).
3. Answer: C. The danger of an overdose during fluid remobilization is
reduced.
 Option C: Although providing some pain relief has a high priority,
and giving the drug by the IV route instead of IM, SC, or orally
does increase the rate of effect, the most important reason is to
prevent an overdose from accumulation of drug in the interstitial
space during the fluid shift of the emergent phase. When edema
is present, cumulative doses are rapidly absorbed when the fluid
shift is resolving. This delayed absorption can result in lethal blood
levels of analgesics.
4. Answer: D. Vitamin D
 Option D: Skin exposed to sunlight activates vitamin D. Partial-
thickness burns reduce the activation of vitamin D. Activation of
vitamin D is lost completely in full thickness burns.
5. Answer: C. The burned areas include the hands and perineum.
 Option C: Burns of the perineum increase the risk for sepsis. Burns
of the hands require special attention to ensure the best
functional outcome.
6. Answer: C. “To decrease hydrochloric acid production in the stomach and
prevent ulcers.”
 Option C: Ulcerative gastrointestinal disease may develop within
24 hours after a severe burn as a result of increased hydrochloric
acid production and decreased mucosal barrier. Cimetidine
inhibits the production and release of hydrochloric acid.
7. Answer: C. During fluid remobilization
 Option C: Hypokalemia is most likely to occur during the fluid
remobilization period as a result of dilution, potassium movement
back into the cells, and increased potassium excreted into the
urine with the greatly increased urine output.
8. Answer: C. Cherry red color to the mucous membranes
 Option C: The saturation of hemoglobin molecules with carbon
monoxide and the subsequent vasodilation induces a “cherry red”
color of the mucous membranes in these clients. The other
manifestations are associated with inhalation injury, but not
specifically carbon monoxide poisoning.
9. Answer: C. Capillary refill is slow in the digits and the distal pulse is
absent.
 Option C: Circumferential eschar can act as a tourniquet when
edema forms from the fluid shift, increasing tissue pressure and
preventing blood flow to the distal extremities and increasing the
risk for tissue necrosis. This problem is an emergency and, without
intervention, can lead to loss of the distal limb. This problem can
be reduced or corrected with an escharotomy.
10. Answer: D. Hemoglobin S electrophoresis
 Option D: Sickle cell disease and sickle cell trait are more common
among African Americans. Although clients with sickle cell disease
usually know their status, the client with sickle cell trait may not.
The fluid, circulatory, and respiratory alterations that occur in the
 emergent phase of a burn injury could result in decreased tissue
perfusion that is sufficient to cause sickling of cells, even in a
person who only has the trait. Determining the client’s sickle cell
status by checking the percentage of hemoglobin S is essential for
any African American client who has a burn injury.
11. Answer: B. Crystalloids
 Option B: Although not universally true, most fluid resuscitation
for burn injuries starts with crystalloid solutions, such as normal
saline and Ringer’s lactate.
 Option D: The burn client rarely requires blood during the
emergent phase unless the burn is complicated by another injury
that involved hemorrhage.
 Options A and C: Colloids and plasma are not generally used
during the fluid shift phase because these large particles pass
through the leaky capillaries into the interstitial fluid, where they
increase the osmotic pressure. Increased osmotic pressure in the
interstitial fluid can worsen the capillary leak syndrome and make
maintaining the circulating fluid volume even more difficult.
12. Answer: B. Loosen the dressing.
 Option B: Respiratory difficulty can arise from external pressure.
The first action in this situation would be to loosen the dressing
and then reassess the client’s respiratory status.
13. Answer: B. Notify the emergency team.
 Option B: Clients with severe inhalation injuries may sustain such
progressive obstruction that they may lose effective movement of
air. When this occurs, wheezing is no longer heard and neither are
breath sounds. The client requires the establishment of an
emergency airway and the swelling usually precludes intubation.
14. Answer: B. Document the finding as the only action.
 Option B: Neural and hormonal compensation to the stress of the
burn injury in the emergent phase increases liver glucose
production and release. An acute rise in the blood glucose level is
an expected client response and is helpful in the generation of
energy needed for the increased metabolism that accompanies
this trauma.
15. Answer: A. Fluid shift
 Option A: Intense pain and carbon monoxide poisoning increase
blood pressure. Hemorrhage is unusual in a burn injury. The
physiologic effect of histamine release in injured tissues is a loss
of vascular volume to the interstitial space, with a resulting
decrease in blood pressure.
16. Answer: B. Document the finding as the only action.
 Option B: Decreased or absent peristalsis is an expected response
during the emergent phase of burn injury as a result of neural and
hormonal compensation to the stress of injury.
 Options A, C, and D: No currently accepted intervention changes
this response, and it is not the highest priority of care at this time.
17. Answer: A. Increased urine output, decreased urine specific gravity
 Option A: The “fluid remobilization” phase improves renal blood
flow, increasing diuresis and restoring fluid and electrolyte levels.
The increased water content of the urine reduces its specific
gravity.
18. Answer: C. Risk for Disuse Syndrome
 Option C: During the emergent phase, fluid shifts into interstitial
tissue in burned areas. When the burn is circumferential on an
extremity, the swelling can compress blood vessels to such an
extent that circulation is impaired distal to the injury,
necessitating the intervention of an escharotomy. Chemical burns
do not cause inhalation injury.
19. Answer: B. Serum potassium 7.5 mmol/L (mEq/L)
 Option B: All these findings are abnormal; however, only the
serum potassium level is changed to the degree that serious, life-
threatening responses could result. With such a rapid rise in the
potassium level, the client is at high risk for experiencing severe
cardiac dysrhythmias and death.
20. Answer: B. Heart rate and rhythm
 Option B: The airway is not at any particular risk with this injury.
Electric current travels through the body from the entrance site to
the exit site and can seriously damage all tissues between the two
sites. Early cardiac damage from electrical injury includes irregular
heart rate, rhythm, and ECG changes.
21. Answer: D. “In what exact place or space were you when you were
burned?”
 Option D: The risk for inhalation injury is greatest when flame
burns occur indoors in small, poorly ventilated rooms.
although smokingincreases the risk for some problems, it does not
predispose the client for an inhalation injury.
22. Answer: C. The client’s oxygen saturation is 97%.
 Option C: Clients may have ineffective respiratory efforts and gas
exchange even though they are able to talk, have good respiratory
movement, and are alert. The best indicator for respiratory
effectiveness is the maintenance of oxygen saturation within the
normal range.
23. Answer: C. The client’s oxygen saturation is 97%.
 Option C: Clients may have ineffective respiratory efforts and gas
exchange even though they are able to talk, have good respiratory
movement, and are alert. The best indicator for respiratory
effectiveness is the maintenance of oxygen saturation within the
normal range.
24. Answer: B. “When the burn wounds are closed.”
 Option B: Intact skin is a major barrier to infection and other
disruptions in homeostasis. No matter how much time has passed
since the burn injury, the client remains at great risk for infection
as long as any area of skin is open.
25. Answer: C. Myocardial infarction 1 year ago
 Option C: It is likely the client has a diminished cardiac output as a
result of the old MI and would be at greater risk for the
development of congestive heart failure and pulmonary edema
during fluid resuscitation.
26. Answer: C. Auscultate breath sounds over the trachea and mainstem
bronchi.
 Option C: Difficulty swallowing and drooling are indications of
oropharyngeal edema and can precede pulmonary failure. The
client’s airway is in severe jeopardy and intubation is highly likely
to be needed shortly.
27. Answer: A. Handwashing on entering the client’s room
 Option A: Cross-contamination occurs when microorganisms from
another person or the environment are transferred to the client.
Although all the interventions listed above can help reduce the
risk for infection, only hand washing can prevent cross
contamination.
28. Answer: C. The “bands” outnumber the “segs.”
 Option C: Normally, the mature segmented neutrophils (“segs”)
are the major population of circulating leukocytes, constituting
55% to 70% of the total white blood count. Fewer than 3% to 5%
of the circulating white blood cells should be the less mature
“band” neutrophils. A left shift occurs when the bone marrow
releases more immature neutrophils than mature neutrophils.
Such a shift indicates severe infection or sepsis, in which the
client’s immune system cannot keep pace with the infectious
process.
29. Answer: C. Have the client turn the head from side to side 90 degrees
every hour while awake.
 Option C: The function that would be disrupted by a contracture
to the posterior neck is flexion. Moving the head from side to side
prevents such a loss of flexion.
30. Answer: D. Hip at zero flexion with leg flat
 Option D: Maximum function for ambulation occurs when the hip
and leg are maintained at full extension with neutral rotation.
Although the client does not have to spend 24 hours at a time in
this position, he or she should be in this position (in bed or
standing) more of the time than with the hip in any degree of
flexion.
31. Answer: D. Increased serum creatinine level
 Option D: Gentamicin does not stimulate pain in the wound. The
small, pale pink bumps in the wound bed are areas of re-
epithelialization and not an adverse reaction. Gentamicin is
nephrotoxic and sufficient amounts can be absorbed through burn
 wounds to affect kidney function. Any client receiving gentamicin
by any route should have kidney function monitored.
32. Answer: D. Notify the burn emergency team.
 Option D: These findings are associated with systemic gram-
negative infection and sepsis. This is a medical emergency and
requires prompt attention.
33. Answer: A. Changing gloves between wound care on different parts of
the client’s body.
 Option A: Autocontamination is the transfer of microorganisms
from one area to another area of the same client’s body, causing
infection of a previously uninfected area. Although all techniques
listed can help reduce the risk for infection, only changing gloves
between carrying out wound care on difference parts of the
client’s body can prevent autocontamination.
34. Answer: D. As soon as possible after resolution of the fluid shift
 Option D: Regular, progressive ambulation is initiated for all burn
clients who do not have contraindicating concomitant injuries as
soon as the fluid shift resolves. Clients can be ambulated with
extensive dressings, open wounds, and nearly any type of
attached lines, tubing, and other equipment.
35. Answer: B. “Because the graft is my own skin, there is no chance it
won’t ‘take’.”
 Option B: Factors other than tissue type, such as circulation and
infection, influence whether and how well a graft “takes.” The
client should be prepared for the possibility that not all grafting
procedures will be successful.
36. Answer: D. “I will be fully recovered when I achieve the highest possible
level of functioning that I can.”
 Option D: Although a return to pre burn functional levels is rarely
possible, burned clients are considered fully recovered or
rehabilitated when they have achieved their highest possible level
of physical, social, and emotional functioning.
37. Answer: D. “My facial scars should be less severe with the use of this
mask.”
 Option D: The purpose of wearing the pressure garment over
burn injuries for up to 1 year is to prevent hypertrophic scarring
and contractures from forming. Scars will still be present.
Although the mask does provide protection of sensitive newly
healed skin and grafts from sun exposure, this is not the purpose
of wearing the mask. The pressure garment will not change the
angle of ear attachment to the head.
38. Answer: B. Impaired Adjustment
 Option B: Recovery from a burn injury requires a lot of work on
the part of the client and significant others. Seldom is the client
restored to the preburn level of functioning. Adjustments to
changes in appearance, family structure, employment
opportunities, role, and functional limitations are only a few of
the numerous life-changing alterations that must be made or
overcome by the client.
 Option A: By the rehabilitation phase, acute pain from the injury
or its treatment is no longer a problem.
39. Answer: C. Permeability of capillary walls
 Option C: In burn, the capillaries and small vessels dilate, and cell
damage cause the release of a histamine-like substance. The
substance causes the capillary walls to become more permeable
and significant quantities of fluid are lost.
40. Answer: C. Limit the occurrence of drafts
 Option C: A Client with burns is very sensitive to temperature
changes because heat is loss in the burn areas.