Burns prepU practice questions
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance.
The palm represents which percentage of a person's TBSA?
1%
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
A urine output consistently above 40 ml/hour
The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury?
Hyperkalemia
Which of the following measures can be used to cool a burn?
Application of cool water
Burn shock is characterized by which of the following
Capillary leak
Which of the following is to be expected soon after a major burn? Select all that apply.
Hypotension Tachycardia Anxiety
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
IV
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
Lund and browder method
Which of the following is the analgesic of choice for burn pain?
Morphine sulfate
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
Myoglobin in the urine
As the first priority of care, a patient with a burn injury will initially need:
a patent airway established.
Which of the following is a common complication of an electrical burn injury?
cardiac dysrhythmias
During the acute phase of a burn, a nurse should assess:
circulatory status
A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus?
decreased peristalsis
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?
gastric ulcers
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
paralytic ileus
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:
Hyperkalemia
After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?
Presence of soot around nasal passages
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?
Reduction in blood volume
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
27%
What quick assessment technique should the nurse use to assess the percentage of burn injury?
Compare the client's palm with the size of the burn wound
The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?
Establish a patent airway
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?
Fluid resuscitation
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?
LR
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.
Singed nasal hair Hoarseness Facial burns
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation
The client's urinary output is 0.3 to 0.5 mL/kg/hour.
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
hoarseness of the voice
Which of the following types of shock will a nurse observe in a client with extensive burns?
hypovolemic shock
Which type of burn is similar to a sunburn?
superficial partial thickness
