Garcia Danica C.

BSN 4-1

1. The nurse is caring for a client who has suffered deep partial-thickness and full-thickness burns.
During the emergent (resuscitative) phase of burn management, the nurse would anticipate a
uid shift from the: 1. Intracellular to extracellular compartment. 2. Extracellular to
intravascular compartment. 3. Interstitial to the intracellular compartment. 4. Intravascular
to the interstitial compartment

Rationale: 4. During the emergent phase of burn management, there is a massive shift of uid from the
blood vessels (intravascular compartment) into the tissues (interstitial compartment). The result of this
shift is hypovolemic shock and edema formation. The uid shift, which occurs between the
intravascular and interstitial extracellular compartments, is caused by increased capillary permeability
that allows water, sodium, and protein to shift to the tissues. As the emergent period ends and capillary
permeability returns to normal, the uid in the interstitial compartment will return to the intravascular
compartment. CN: Physiological adaptation; CL: Analyze

2. The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas.
Which position would be most appropriate for preventing contractures? 1. High Fowlers. 2.
Semi-Fowlers. 3. Prone. 4. Supine.

Rationale: 4. A supine position in extension is the position most likely to prevent contractures. Clients
who have experienced burns will nd a exed position most comfortable. However, exion promotes
the development of contractures. The high Fowlers and semi-Fowlers positions create hip exion. The
prone position is contraindicated because of head and neck burns. In clients with head and neck burns,
pillows should not be used under the head or neck because it promotes neck exion contractures. CN:
Reduction of risk potential; CL: Synthesize

3. During the emergent stage of burn management for a client with burns of 30 percent of the
body the nurse should assess the client for which of the following? Select all that apply. 1.
Hyponatremia. 2. Hyperkalemia. 3. Hypoglycemia. 4. Increased hematocrit. 5. Fever
spikes.

Rationale: 2, 4, 5. In the emergent phase of burn management, hyperkalemia develops as a result of the
destruction of red blood cells. The hematocrit is increased in response to the plasma loss that has
occurred and the resulting hemoconcentration. Initially, hyponatremia may occur as sodium shifts into
the interstitial spaces. Fever spikes of 102 to 103 degrees are common during this stage. The client will
have hyperglycemia due to decreased levels of insulin production. CN: Physiological adaptation; CL:
Analyze

4. What is the priority nursing intervention for a client who is admitted to the emergency
department with burns over an estimated 27% of the body surface area? 1. Insert a large-
caliber I.V. line. 2. Administer morphine intramuscularly. 3. Establish an airway. 4.
Administer tetanus toxoid.

Rationale: 3. Establishing a patent airway is the priority intervention. Prophylactic intubation is initiated
if heat has been inhaled or if the neck, head, or face is involved. Swelling of the upper airways can
progress to obstruction. Fluid replacement can best be achieved using a large-caliber peripheral I.V.
catheter, and morphine sulfate is appropriate for analgesia in a burn client. Although these are
priorities, they are secondary to establishing a patent airway. Administering tetanus toxoid is a
secondary priority. CN: Reduction of risk potential; CL: Synthesize

5. The nurse is evaluating the effectiveness of uid resuscitation during the emergency period of
burn management. Which of the following indicates that adequate uid replacement has been
achieved in the client? 1. An increase in body weight. 2. Fluid intake less than urinary
output. 3. Urine output greater than 35 mL/hour. 4. Blood pressure of 90/60 mm Hg

Rationale: 3. A urine output of 30 to 50 mL/hour indicates adequate uid replacement in the client with
burns. An increase in body weight may indicate uid retention. A urine output greater than uid intake
does not represent a uid balance. Depending on the client, blood pressure of 90/60 mm Hg could
indicate the presence of a hypovolemic state; by itself, it does not indicate adequate uid replacement.
CN: Physiological adaptation; CL: Evaluate

6. A father of a toddler brings his child to the emergency room because the child has
accidentally been scalded by hot water spilling from the stove. In order to differentiate the burn from
potential abuse, the nurse rst should assess the child: 1. On the back of the body. 2. On the front
of the body. 3. For a circular or glove pattern. 4. On the buttocks.

Rationale: 2. Accidental scaldings are usually splash-related and occur on the front of the body. Any
burns on the back of the body or in a wellde ned circular or glove pattern may indicate physical abuse.
Immersion burns on the buttocks are also suspicious injuries. CN: Health promotion and maintenance;
CL: Analyze
 7. The nurse establishes the goal of preventing the development of a stress ulcer in a burn client.
Which of the following interventions would most likely contribute to the achievement of this
goal? 1. Implementing relaxation exercises. 2. Administering a sedative as needed. 3.
Providing a soft, bland diet. 4. Administering famotidine (Pepcid) as ordered.

Rationale: 4. Clients with burns are susceptible to the development of Curlings ulcer, a gastroduodenal
ulcer that is caused by a generalized stress response. The stress response results in increased gastric acid
secretion and a decreased production of mucus. Prevention is the best treatment, and clients are
frequently treated prophylactically with antacids and H2 histamine blockers such as famotidine (Pepcid).
CN: Reduction of risk potential; CL: Synthesize

8. The mother calls the nurse to report that her toddler just been burned on the arm. The nurse
should advise the mother to rst: 1. Pack the arm in ice, then take the child to the closest
emergency department. 2. Rub the burned area with an antibacterial ointment, then call the
doctor. 3. Run cool water over the burned area, then wrap it in a clean cloth. 4. Call the
childs health care provider immediately, then wrap the arm in a clean cloth.

Rationale: 3. The best advice for the nurse to give the childs mother is to run cool water over the
burned area to stop the burning process. Then the area should be wrapped in a clean cloth. Once these
initial actions are completed, the mother can call the childs physician. Packing the arm in ice may cause
more damage to the burned area because cold can cause burns just as heat can. For most burns, it is not
advised to apply ointment until the area has been evaluated. CN: Reduction of risk potential; CL:
Synthesize

9. A child with partial- and full-thickness burns is admitted to the pediatric unit. Which of the
following should be the priority at this time? 1. Preventing wound infection. 2. Evaluating
vital signs frequently. 3. Maintaining uid and electrolyte balance. 4. Managing the childs
pain.

Rationale: 3. Although monitoring vital signs frequently is important, for the rst few days the primary
concern in burn care is uid and electrolyte balance, with the goal being to replace uid and
electrolytes lost. With burns, uid and electrolytes move from the interstitial spaces to the burn injury
and are lost. These must be replaced. Once the childs uid and electrolyte status has been addressed
and uid resuscitation has begun, preventing wound infection is a priority and efforts to control the
childs pain can be initiated. CN: Physiological adaptation; CL: Synthesize
 10. What is the primary goal of nursing care during the emergent phase after a burn injury? 1.
Replace lost uids. 2. Prevent infection. 3. Control pain. 4. Promote wound healing.

Rationale: 1. During the emergent phase of burn care, one of the most signi cant problems is
hypovolemic shock. The development of hypovolemic shock can lead to impaired blood ow through
the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed
toward replacing lost uids and preventing hypovolemic shock. Preventing infection and controlling
pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the
stage of burn injury to promote wound healing. CN: Physiological adaptation; CL: Synthesize

11. The client with a burn injury is assessed using the rule of nines to determine which of the
following? 1. Amount of body surface area burned. 2. Rehabilitation needs. 3. Respiratory
needs. 4. Type of intravenous uids required.

Rationale: 1. The rule of nines is used to determine the percentage of the clients body surface area
that was burned. Medical treatment, including uid volume replacement therapy, is based on the
percentage of body surface area burned. CN: Physiological adaptation; CL: Analyze

12. While the nurse is assisting a client to ambulate as part of his cardiac rehabilitation program,
the client tells the nurse he is having midsternal burning. The nurse should next: 1. Stop and
assess the client further. 2. Measure the clients blood pressure and heart rate. 3. Call for
help and place the client in a wheelchair. 4. Administer nitroglycerin.

Rationale: 1. The nurse should stop and assess the client further. A chair should be available for the
client to sit down. Obtaining the clients blood pressure and heart rate are important when exercising.
These values can be used to predict when the oxygen demand becomes greater than the oxygen supply.
Calling for help is not necessary for the complaint of midsternal burning. If the physician has ordered
nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen
balance. CN: Physiological adaptation; CL: Synthesize 127. 2, 3, 4. Vitamin B6, folate, and vitamin B12
have been shown to reduce homocysteine levels. The effects of vitamins K and D have not been
established with regard to homocysteine. CN: Health promotion and maintenance; CL: Synthesize

13. A 10-year-old has just spilled hot liquid on his arm, and a 4-inch area on his forearm is severely
burned. His mother calls the emergency department. What should the nurse advise the mother
 to do? 1. Keep the child warm. 2. Cover the burned area with an antibiotic cream. 3. Apply
cool water to the burned area. 4. Call 911 to transport the child to the hospital.

Rationale: 3. To prevent further injury to the skin, the mother should apply cool water to the burn site.
Doing so causes vasoconstriction, retards further damage to tissues, and decreases uid loss. Keeping
the child warm promotes vasodilation, increases uid loss, and decreases blood pressure and, thus,
circulation to the area. Applying ointment to the burn is contraindicated because it does not allow
healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover
the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911
for emergency care is not necessary, but the mother should seek health care services immediately. CN:
Health promotion and maintenance; CL: Synthesize 3. To prevent further injury to the skin, the mother
should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to
tissues, and decreases uid loss. Keeping the child warm promotes vasodilation, increases uid loss,
and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is
contraindicated because it does not allow healing to occur and may need to be removed in the hospital.
Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or
chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother
should seek health care services immediately. CN: Health promotion and maintenance; CL: Synthesize

14. The nurse is assessing a 9-year-old child who has third-degree burns as shown below. Using the
Rule of Nines adapted for children, the nurse estimates that the extent of burns for this child
is: 1. 9%. 2. 14%. 3. 18%. 4. 24%.

Rationale: 2. The child has burns of the entire leg. Because of the smaller size of childrens legs, the
estimate of 14% is used instead of 18%, which is used with adults. The arms of children are estimated at
9%, and the anterior and posterior trunk at 18% each. The head of the child is estimated at 18%, rather
than the 9% used for adults. CN: Physiological adaptation; CL: Analyze 9. 250 mL/hour 2,000 mL 8
hours = 250 mL/hour

CN: Pharmacological and parenteral therapies; CL: Apply

15. Which of the following would be most appropriate to institute when a school-age child with
burns becomes angry and combative when it is time to change the dressings and apply mafenide
acetate (Sulfamylon)? 1. Ensure parental support during the dressing changes. 2. Allow the
child to assist in removing the dressings and applying the cream. 3. Give the child permission
to cry during the procedure. 4. Allow the child to schedule the time for dressing changes.
Rationale: 2. Expressions of anger and combativeness are often the result of loss of control and a feeling
of powerlessness. Some control over the situation is regained by allowing the child to participate in care.
Although having parental support during the dressing changes may be helpful, this action does nothing
to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing
so does nothing to provide the child with control over the situation. Although allowing the child to
determine the time for dressing changes may provide a sense of control over the situation, doing so is
inappropriate because the dressing changes need to be performed as ordered to ensure effectiveness
and healing. CN: Physiological adaptation; CL: Synthesize

16. A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and mother
develop a plan of care to stimulate the childs appetite. Which of the following suggestions
made by the mother would indicate that she needs additional teaching? 1. Deciding that she
will feed the child herself. 2. Withholding dessert and treats unless meals are eaten. 3.
Offering the child nger foods that the child likes. 4. Serving smaller and more frequent
meals.

Rationale: 2. Withholding certain foods until the child complies is punitive and rarely successful.
Allowing the mother to feed the child, serving smaller and more frequent meals, and offering nger
foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.
CN: Basic care and comfort; CL: Evaluate

17. After teaching the mother of a child with severe burns about the importance of speci c
nutritional support in burn management, which of the following, if chosen by the mother from
the childs diet menu, indicates the need for further instruction? 1. Bacon, lettuce, and
tomato sandwich; milk; and celery and carrot sticks. 2. Cheeseburger, cottage cheese and
pineapple salad, chocolate milk, and a brownie. 3. Chicken nuggets, orange and grapefruit
sections, and a vanilla milkshake. 4. Beef, bean, and cheese burrito; a banana; fruit- avored
yogurt; and skim milk.

Rationale: 1. Hypoproteinemia is common after severe burns. The childs diet should be high in protein
to compensate for protein loss and to promote tissue healing. The child will also require a diet that is
high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and celery
sticks is lacking in suf cient protein and calories. CN: Physiological adaptation; CL: Evaluate

18. When caring for a child with moderate burns from the waist down, which of the following
should the nurse do when positioning the child? 1. Place the child in a position of comfort.
 2. Allow the child to lie on the abdomen. 3. Ensure the application of leg splints. 4. Have the
child ex the hips and knees.

Rationale: 3. A child with moderate burns is at high risk for contractures. A position of comfort would
encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning
and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the
abdomen or with hips and knees exed often encourages contracture formation. CN: Reduction of risk
potential; CL: Synthesize

19. A client with macrocytic anemia has a burn on her foot and states that she had been watching
television while lying on a heating pad. Which action should be the nurses rst response? 1.
Assess for potential abuse. 2. Check for diminished sensations. 3. Document the ndings.
4. Clean and dress the area.

Rationale: 2. Macrocytic anemias can result from de ciencies in vitamin B12 or ascorbic acid. Only
vitamin B12 de ciency causes diminished sensations of peripheral nerve endings. The nurse should
assess for peripheral neuropathy and instruct the client in self-care activities for her diminished
sensation to heat and pain (e.g., using a heating pad at a lower heat setting, making frequent checks to
protect against skin trauma). The burn could be related to abuse, but this conclusion would require
more supporting data. The ndings should be documented, but the nurse would want to address the
clients sensations rst. The decision of how to treat the burn should be determined by the physician.
CN: Reduction of risk potential; CL: Synthesize

20. A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent
breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse
should further assess the client for indications of: 1. Hiatal hernia. 2. Stomatitis. 3.
Radiation enteritis. 4. Esophagitis.

Rationale: 4. Dif culty in swallowing, pain, and tightness in the chest are signs of esophagitis, which is a
common complication of radiation therapy of the chest wall. Hiatal hernia is a herniation of a portion of
the stomach into the esophagus. The client could experience burning and tightness in the chest
secondary to a hiatal hernia, but not pain when swallowing. Also, hiatal hernia is not a complication of
radiation therapy. Stomatitis is an i n ammation of the oral cavity characterized by pain, burning, and
ulcerations. The client with stomatitis may experience pain with swallowing, but not burning and
tightness in the chest. Radiation enteritis is a disorder of the large and small bowel that occurs during or
after radiation therapy to the abdomen, pelvis, or rectum. Nausea, vomiting, abdominal cramping, the
frequent urge to have a bowel movement, and watery diarrhea are the signs and symptoms. CN:
Physiological adaptation; CL: Analyze