Nursing Care Of Patients With Burns Ch.17 Test Bank Answers - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 17 Nursing Care of Patients with Burns
1) A patient receives a chemical burn from contact with lye. Which information should guide the planning of care for this patient? Select all that apply.
1. This is an alkali burn.
2. This type of burn tends to be deeper.
3. This is an acid burn.
4. This type of burn is easier to neutralize.
5. This type of burn tends to be more superficial.
Page Ref: 520
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
2) A patient receives an electrical burn. What assessment question should the nurse ask to determine the severity of the burn injury? Select all that apply.
1. What type of current was involved?
2. How long was the patient in contact with the current?
3. How much voltage was involved?
4. Where was the patient when the burn occurred?
5. What was the point of contact with the current?
Page Ref: 521
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
3) A patient gets struck by lightning during a thunderstorm on a golf course. What is the first action that should occur in this patient's care?
1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the victim to prevent heat loss.
4. Move the victim indoors to a dry place.
Page Ref: 521
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
4) The nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in this discussion? Select all that apply.
1. Drain cleaners
2. Household ammonia
3. Oven cleaner
4. Toiler bowl cleaner
5. Lemon oil furniture polish
Page Ref: 520
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
5) A patient has a burn that is pale, waxy, and with large flat blisters. What should the nurse respond when asked about the severity and healing time of the injury?
1. The wound is a deep partial-thickness burn and will take more than 3 weeks to heal.
2. The wound is a superficial partial-thickness burn and could take up to 2 weeks to heal.
3. The wound is a superficial burn and will take up to 3 weeks to heal.
4. The wound is a full-thickness burn and will take 1 to 2 weeks to heal.
Page Ref: 522
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
6) The nurse is assessing a patient's burns. What information should the nurse assess to classify this injury? Select all that apply.
1. Depth of the burn
2. Extent of burns on the body
3. Causative agent and duration of exposure
4. Location of burns on the body
5. Time that the burns occurred
Page Ref: 521-524
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
7) A patient has a scald burn on the arm that is bright red, moist, and has several blisters. How should this burn be classified? Select all that apply.
1. Superficial partial-thickness burn
2. Thermal burn
3. Superficial burn
4. Deep partial-thickness burn
5. Full-thickness burn
Page Ref: 521
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
8) A patient has the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines. ________% Record your answer rounding to the nearest whole number.
Page Ref: 523-524
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
9) A patient has partial-thickness burns on both lower legs, over 20% of the total body surface area. How should the nurse classify this burn?
1. Moderate burn injury
2. Minor burn injury
3. Major burn injury
4. Severe burn injury
Page Ref: 523
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
10) A patient has sustained a partial-thickness burn of 28% of total body surface area (TBSA) and full-thickness burn of 30% or greater of TBSA. How should the nurse classify this burn injury?
1. Major
2. Moderate
3. Minor
4. Superficial
Page Ref: 523
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
11) An older patient is sunburned over much of the body. What self-care technique is MOST important for the nurse to emphasize to this patient?
1. Increasing fluid intake
2. Applying mild lotions
3. Taking mild analgesics
4. Maintaining warmth
Page Ref: 525-526
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching/Learning
Learning Outcome: 17.4 Describe the pathophysiology and manifestations of minor burns of the skin, and outline the interprofessional care and nursing care of patients with minor burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
12) A patient was treated for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's teaching? Select all that apply.
1. Report any fever to the healthcare provider.
2. Report any purulent drainage to the healthcare provider.
3. Use only sterile dressings on the fingers.
4. Cleanse the areas every hour with alcohol to prevent infection.
5. Apply a topical antimicrobial agent as instructed.
Page Ref: 525-526
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 17.4 Describe the pathophysiology and manifestations of minor burns of the skin, and outline the interprofessional care and nursing care of patients with minor burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
13) A patient with severe burns to the torso and upper extremities has edema around the burned areas. How should the nurse describe the underlying cause for this assessment finding?
1. Inability of the damaged capillaries to maintain fluids in the cell walls
2. Reduced vascular permeability in the burned area
3. Decreased osmotic pressure in the burned tissue
4. Increased fluids in the extracellular compartment
Page Ref: 527
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
14) A patient receiving treatment for severe burns over more than half the body has an indwelling urinary catheter. When evaluating the patient's intake and output, what should the nurse take into consideration?
1. Urine output will be reduced in the first 24-48 hours and will then increase.
2. Urine output will be greatest in the first 24 hours after the burn injury.
3. Urine output will be reduced during the first 8 hours and will then increase as diuresis begins.
4. Urine output will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
Page Ref: 81-82
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
15) The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major burn event on 45% of the body 24 hours ago. Which result should the nurse expect for this patient? Select all that apply.
1. Glomerular filtration rate (GFR) reduced
2. Specific gravity elevated
3. Creatinine clearance reduced
4. BUN reduced
5. Uric acid decreased
Page Ref: 529, 532
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.
16) The nurse is evaluating laboratory values for a patient with a burn injury. What results should the nurse expect for this patient?
1. Decreased hemoglobin and elevated hematocrit levels
2. Elevated hemoglobin and elevated hematocrit levels
3. Elevated hemoglobin and decreased hematocrit levels
4. Decreased hemoglobin and decreased hematocrit levels
Page Ref: 532
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.
17) When monitoring the vital signs of a patient who has sustained a major burn injury, the nurse assesses a heart rate of 112. What should the nurse determine about this finding?
1. This heart rate is normal for the patient's post-burn injury condition.
2. The patient is demonstrating manifestations consistent with the onset of an infection.
3. The patient is demonstrating manifestations consistent with an electrolyte imbalance.
4. The patient is demonstrating manifestations consistent with renal failure.
Page Ref: 540
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.
18) A patient has sustained a burn injury. Which nursing intervention is of the highest priority at this time?
1. Determine the type of burn injury
2. Determine the types of home remedies attempted prior to the patient's coming to the hospital
3. Assess past medical history
4. Measure body weight
Page Ref: 520
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
19) A patient is scheduled for surgery to graft a burn injury on the arm. Which statement should the nurse include when instructing the patient about the procedure?
1. "You will begin to perform exercises to promote flexibility and reduce contractures after 5 days."
2. "You will need to report any itching, as it might signal infection."
3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve the chances of success."
4. "The procedure will be performed in your room."
Page Ref: 536
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
20) A patient recovering from a major burn injury is complaining of pain. Which medication should the nurse expect to be prescribed for this patient?
1. Morphine 4 mg IV every 5 minutes
2. Morphine 10 mg IM ever 3-4 hours
3. Meperidine 75 mg IM every 3-4 hours
4. Meperidine 50 mg PO every 3-4 hours
Page Ref: 533
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
21) A patient with a burn injury is prescribed silver nitrate. Which nursing intervention should be included in the plan of care for this patient? Select all that apply.
1. Monitor daily weight.
2. Monitor serum sodium levels.
3. Prepare to change the dressings every 2 hours.
4. Report black skin discolorations.
5. Saturate the dressings every 2 hours with a 0.5% aqueous solution of silver nitrate.
Page Ref: 534
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
22) The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which laboratory value indicates the need to adjust the patient's nutritional program?
1. Glycosuria
2. Creatine phosphokinase (CPK)
3. BUN levels
4. Hemoglobin
Page Ref: 532
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.
23) A patient is beginning the acute phase of burn treatment. What should the nurse anticipate as priorities for this patient's care? Select all that apply.
1. Wound care
2. Nutritional therapy
3. Infection control
4. Graft procedures
5. Home maintenance management
Page Ref: 539, 541
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
24) A patient is admitted to the emergency department with deep partial-thickness burns over 35% of the body. What IV solution will be started initially?
1. Warmed lactated Ringer's solution
2. Dextrose 5% with saline solution
3. Dextrose 5% with water
4. Normal saline solution
Page Ref: 531
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
25) Using the Consensus formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a burn patient with 40% TBSA, weight of 52 kg, and prescribed 2 mL/kg. ________ mL Record your answer rounding to the nearest whole number.
Page Ref: 531
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
26) The family of a patient with third-degree burns wants to know why "the scabs are being cut off" the patient's leg. What is the most appropriate response by the nurse?
1. "The scabs are really old burned tissue and need to be removed to promote healing."
2. "I'll ask the doctor to come and talk with you about the treatment plan."
3. "The patient asked for the scabs to be removed."
4. "The scabs are removed to check for blood flow to the burned area."
Page Ref: 535
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
27) A patient with third-degree burns is prescribed gastrointestinal medication. How should the nurse explain the primary action of this medication?
1. It prevents the formation of a Curling ulcer.
2. It treats a preexisting duodenal ulcer.
3. It ensures adequate peristalsis.
4. It has antiemetic properties.
Page Ref: 535
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
28) A patient with third-degree burns has a reduction in the serum potassium level. To which event is this laboratory value related?
1. Resolution of burn shock
2. Onset of burn shock
3. Onset of renal failure
4. Onset of liver failure
Page Ref: 532
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.
29) A patient being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. What does the nurse realize is the most likely reason?
1. The patient is developing hypersensitivity to the medication.
2. The patient is reacting positively to the medication.
3. The patient needs an increase in dosage of the medication.
4. The patient is not responding to the medication.
Page Ref: 534
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
30) Following surgical debridement, a patient with third-degree burns does not bleed. What should this outcome suggest to the nurse?
1. The procedure will need to be repeated.
2. The patient will no longer need this procedure.
3. The patient will need to be premedicated prior to the next procedure.
4. The patient should have an escharotomy instead.
Page Ref: 536
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
31) The nurse applies Elase to a third-degree burn on a patient's left thigh and left forearm. Which type of wound debridement is the nurse using?
1. Enzymatic
2. Mechanical
3. Surgical
4. Topical
Page Ref: 537
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
32) A patient with full thickness burns is being treated with high-volume intravenous fluids and has a urine output of 40 mL per hour. What does the nurse realize about this urine output?
1. It is normal for this patient.
2. It is evidence that the patient is dehydrated.
3. It is evidence that the patient is overhydrated.
4. It indicates pending renal failure.
Page Ref: 540
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
33) A patient with third-degree burns on the right arm is scheduled for passive range of motion to the extremity every 2 hours. What should the nurse do prior to this exercise session?
1. Medicate the patient for pain.
2. Empty the patient's indwelling catheter collection bag.
3. Change the patient's bed linens.
4. Change the dressing on the burn.
Page Ref: 540
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Basic Care and Comfort
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
34) A patient with third-degree burns to the face learns that there will be extensive scarring once the burn heals. For which patient problem should the nurse plan interventions?
1. Powerlessness
2. Infection
3. Lack of body fluids
4. Changes in airway maintenance
Page Ref: 542-543
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Grief and Loss
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Ethical Comportment; Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
35) A patient seeks medical attention for a burn that appears moist with blisters. For which type of burn should the nurse plan care for this patient?
1. Superficial
2. Superficial partial-thickness
3. Deep partial-thickness
4. Full thickness
Page Ref: 521
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.2 Explain burn classification by depth and extent of injury.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
36) A patient reports nausea, vomiting, chills, and a headache after spending the weekend at a seaside resort. On which assessment should the nurse focus?
1. Sleeping pattern
2. Eating pattern
3. Travel issue including time zone changes
4. Time spent in the sun causing a sunburn
Page Ref: 521
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
37) A patient receives a chemical burn to the left side of the face and right wrist. Where does this patient need to be treated?
1. Outpatient ambulatory clinic
2. Emergency department
3. Burn center
4. Healthcare provider's office, and then at home
Page Ref: 530
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
38) The nurse notes an area of stasis around a patient's burn. What changes should the nurse expect to assess in this area over the next week? Select all that apply.
1. The area becomes pale.
2. The area develops necrosis.
3. The area blanches on pressure.
4. The area appears like other skin surfaces.
5. The area appears leathery and coagulated.
Page Ref: 527
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.
39) A victim of a fire in a clothing shop is complaining of headache and dizziness and has a potentially dangerous heart rhythm. What should the nurse expect to be prescribed for this patient? Select all that apply.
1. Treatment with prednisone
2. Treatment with vancomycin
3. Treatment with hydroxocobalamin
4. Hyperbaric oxygen therapy
5. Pacemaker insertion
Page Ref: 528
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.
40) The nurse is concerned that an older patient is at risk for a burn injury in the home. What should the nurse instruct the patient to do to reduce this risk? Select all that apply.
1. Check routinely for the odor of gas.
2. Suggest that no one smokes in the home.
3. Wear loose-fitting clothing when cooking.
4. Check the smoke detector battery annually.
5. Keep the hot water heater temperature at 120°F.
Page Ref: 539
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 17.1 Discuss the types and causative agents of burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
41) A patient recovering from a 30% TBSA full-thickness burn has swelling and inflammation of the intact skin around the burn area. What intervention should the nurse implement to reduce this patient's risk of developing a further infection? Select all that apply.
1. Report results of blood cultures.
2. Analyze daily leukocyte counts.
3. Follow strict isolation techniques.
4. Request placement of an indwelling catheter.
5. Request a dietary consult to ensure adequate nutritional intake.
Page Ref: 541
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.
42) A patient is receiving emergent care for burns over 45% of TBSA. What should the nurse realize is occurring during the inflammation phase of these injuries? Select all that apply.
1. Epithelial cells cover the wound.
2. Granulation tissue begins to form.
3. Fibrin is deposited within the damaged tissue.
4. Aggregation of platelets within the damaged tissue.
5. Hemostasis walls off the wound from systemic circulation.
Page Ref: 524-525
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.3 Outline the three stages of burn wound healing.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
43) A patient who sustained full-thickness burns six months ago is being evaluated for ongoing care needs. Which finding indicates that the patient's wounds are in the remodeling phase of healing? Select all that apply.
1. Scars fading in color
2. Hypertrophic scarring
3. Scattered areas of keloids
4. Granulation tissue is present
5. Burned tissue resembles neighboring tissue
Page Ref: 525
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.3 Outline the three stages of burn wound healing.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.
Document Information
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