1. Your adult patient has partial- and full-
Cyanide
thickness burn injuries to his anterior chest,
anterior abdomen, and entire right arm.
Using the rule of nines, the percent of total
body surface area involved can be
estimated at:
● A. 18%.
● B. 27%.
● C. 45%.
● D. 50%.
Rationale: Answer: B. The anterior chest
and abdomen constitute 18% of the BSA,
and the entire right arm is 9%, for a total of
27%.
2. A patient admitted to the ED is suspected
of taking an overdose of atropine. Which
clinical finding would you look for?
● A. Kussmaul respirations
● B. Diarrhea and nausea and
vomiting
● C. Hot, dry skin and dilated pupils
● D. Extrapyramidal tremors
Rationale: Answer: C. A patient who has
overdosed on atropine will have
flushed, dry skin and dilated pupils.
3. Your patient has a core body temperature
of 80° F (26.7° C). Which classification of
hypothermia is this?
● A. Low
● B. Mild
● C. Moderate
● D. Severe
Rationale: Answer: D. Severe hypothermia
is a core body temperature of
less than 82.4° F ( 28° C).
4. An unconscious patient is admitted to the
ED with a very strong wintergreen odor on
his breath. What might he have ingested?
● A. Ethanol
● B. Acetone
● C. Methyl salicylates
● D.
Rationale: Answer: C. If a patient has
ingested methyl salicylates, his breath will
have a wintergreen odor.
1. A 65 year old male patient has
experienced full-thickness electrical burns
on the legs and arms. As the nurse you
know this patient is at risk for the following:
Select all that apply:
A. Acute kidney injury
B. Dysrhythmia
C. Iceberg effect
D. Hypernatremia
E. Bone fractures
F. Fluid volume overload
The answers are A, B, C, and E. Electric
burns are due to an electrical current
passing through the body that leads to
damage to the skin but also the muscles
and bones that are underneath the skin.
The patient is at risk for AKI (acute kidney
injury) because when the muscles become
affected they release myoglobin and the red
blood cells release hemoglobin in the blood,
which can collect in the kidneys leading to
injury. In addition, the heart's electrical
system can become damaged leading to
dysrhythmia. The iceberg effect can present
as well because the extent of damage is not
clearly visible on the skin (there can be
severe damage underneath). In addition, if
the electrical current is strong enough it can
lead to bone fractures (specifically cervical
spine injuries) due to the severe contraction
of the muscles involved.
2. True or False: A patient who experiences
an alkali chemical burn is easier to treat
because the skin will neutralize the
chemical rather than with an acidic chemical
burn.
True
False
False: Alkali burns are harder to treat than
acidic chemical burns because the skin will
neutralize the acidic burn.
3. As the nurse providing care to a patient
who experienced a full-thickness electrical
burn you know to monitor the patient's urine
for:
A. Hemoglobin and myoglobin
B. Free iron and white blood cells
C. Protein and red blood cells
D. Potassium and Urea
The answer is A. Patients who've
experienced a severe electrical burn or full-
thickness burns are at risk for acute kidney
injury. This is because the muscles can
experience damage from the electrical
current leading them to release myoglobin.
In addition, the red blood cells will release
hemoglobin. These substances will collect
in the kidneys leading to acute tubular
necrosis (hence leading to AKI). Therefore,
the nurse should monitor the patient's urine
for these substances.
4. Select the patient below who is at MOST
risk for complications following a burn:
A. A 42 year old male with partial-thickness
burns on the front of the right and left arms
and legs.
B. A 25 year old female with partial-
thickness burns on the front of the head and
neck and front and back of the torso.
C. A 36 year old male with full-thickness
burns on the front of the left arm.
D. A 10 year old with superficial burns on
the right leg.
The answer is B. When thinking about
which patient will have the MOST
complications following a burn think about:
percentage of the total body surface area
that is burned (use the rule of nine to
calculate), depth of the burn, age, location
of the burn, and patient’s medical history.
The patient in option B has 40.5% TSBA
burned (option A 27%, C: 4.5%, D: 9%).
Remember that the higher the total of the
body surface area that is burned the higher
the risk of complications due to an increase
in capillary permeability (swelling,
hypovolemic shock etc.). In addition, the
location of the burn is a major issue with the
patient in option B. The burns are on the
head and neck and front and back of the
torso. Therefore, with head and neck burns
always think about respiratory issues
because the airway can become
compromised due to swelling or an
inhalation injury. And with torso burns that
are on the front and back, the patient is at
risk for circumferential burns that can lead
to further respiratory compromise. The other
options have burns that are isolated.
5. The _____________ layer of the skin
helps regulate our body temperature.
A. Epidermis
B. Dermis
C. Hypodermis
D. Fascia
The answer is C. This layer contains fatty
tissue, veins, arteries, nerves and helps
insulate the muscles, bones, organs and
helps REGULATE our body temperature.
6. You receive a patient who has
experienced a burn on the right leg. You
note the burn contains small blisters and is
extremely pinkish red and shiny/moist. The
patient reports severe pain. You document
this burn as:
A. 1st Degree (superficial)
B. 2nd Degree (partial-thickness)
C. 3rd Degree (full-thickness)
D. 4th Degree (deep full-thickness)
The answer is B. These are the classic
characteristics of a 2nd degree (partial-
thickness) burn.
7. Based on the depth of the burn in figure 1
(picture is above), you would expect to find:
A. report of sensation to only pressure
B. blanching
C. anesthetization to feeling
D. extreme pain
The answer is C. This is a 3rd degree to 4th
degree burn (full-thickness) and the nerves
that detect pain are destroyed. The patient
would have no feeling or experiences an
extreme decrease sensation to pain.
8. A 58 year old female patient has
superficial partial-thickness burns to the
anterior head and neck, front and back of
the left arm, front of the right arm, posterior
trunk, front and back of the right leg, and
back of the left leg. Using the Rule of Nines,
calculate the total body surface area
percentage that is burned?
A. 63%
B. 81%
C. 72%
D. 54%
The answer is A. Anterior head and neck
(4.5%), front and back of the left arm (9%),
front of the right arm (4.5%), posterior trunk
(18%), front and back of the right leg (18%),
back of the left leg (9%) which equals 63%.
9. A 30 year old female patient has deep
partial thickness burns on the front and back
of the right and left leg, front of right arm,
and anterior trunk. The patient weighs 63
kg. Use the Parkland Burn Formula: What is
the flow rate during the FIRST 8 hours
(mL/hr) based on the total you calculated?
A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/hr
D. 789 mL/hr
The answer is A: 921 mL/hr....First calculate
the total amount of fluid needed with the
formula: Total Amount of LR = 4 mL x BSA
% x pt's weight in kg. The pt's weight 63 kg.
BSA percentage: 58.5%...Front and back of
right and left leg (36%), front of right arm
(4.5%), anterior trunk (18%) which equals
58.5%. ......4 x 58.5 x 63 = 14,742
mL......Remember during the FIRST 8 hours
1/2 of the solution is infused, which will be
14,742 divided by 2 = 7371 mL......Hourly
Rate: 7371 divide by 8 equals 921 mL/hr
10. A patient has a burn on the back of the
torso that is extremely red and painful but
no blisters are present. When you pressed
on the skin it blanches. You document this
as a:
A. 1st degree (superficial) burn
B. 2nd degree (partial-thickness) burn
C. 3rd degree (full-thickness) burn
D. 4th degree (deep full-thickness) burn
The answer is A. These are the classic
characteristics of a 1st degree, superficial
burn.
11. A patient has experienced full-thickness
burns to the face and neck. As the nurse it
is priority to:
A. Prevent hypothermia
B. Assess the blood pressure
C. Assess the airway
D. Prevent infection
The answer is C. Due to the location of the
burns (face and neck), the patient is at
major risk for respiratory issues due to
damage to the upper airways and the risk of
an inhalation injury.
12. A patient is in the acute phase of burn
management. The patient experienced full-
thickness burns to the perineum and sacral
area of the body. In the patient’s plan of
care, which nursing diagnosis is priority at
this time?
A. Impaired skin integrity
B. Risk for fluid volume overload
C. Risk for infection
D. Ineffective coping
The answer is C. The patient is now in the
acute phase where fluid resuscitation was
successful and ends with wound closure.
Therefore, during this stage diuresis occurs
(so fluid volume deficient could occur NOT
overload) and INFECTION. The location of
the burns increases the risk of infection
because these areas naturally harbor
bacteria. Therefore, this takes priority
because during this phase wound healing is
promoted.
13. The nurse notes a patient has full-
thickness circumferential burns on the right
leg. The nurse would: select all that apply
A. Place cold compressions on the burn and
elevate the right leg below the heart level
B. Assess the distal pulses in the right
extremity
C. Elevate the right leg above the heart
level
D. Place gauze securely around the leg to
prevent infection
The answer is B and C. The patient has
burns that completely surround the front and
back of the right leg. This can lead to
compartment syndrome where the edema
from the burn compromises circulation to
the distal extremity. The nurse should
elevate the extremity ABOVE heart level to
decrease swelling and assess distal pulses
in the extremity to confirm circulation is
present.
14. A patient arrives to the ER with full-
thickness burns on the front and back of the
torso and neck. The patient has no spinal
injuries but is disoriented and coughing up
black sooty sputum. Vital signs are: oxygen
saturation 63%, heart rate 145, blood
pressure 80/56, and respiratory rate 39. As
the nurse you will:
A. Place the patient in High Fowler’s
positon.
B. Prep the patient for escharotomy.
C. Prep the patient for fasciotomy.
D. Prep the patient for intubation.
E. Place a pillow under the patient’s neck.
F. Obtain IV access at two sites.
G. Restrict fluids.
The answers are A, B, D, and F. After
reading this scenario the location of the
burns and the patient’s presentation should
be jumping out at you. The patient is at risk
for circumferential burns due to the location
of the burns and the depth (full-
thickness….will have eschar present that
will restrict circulation or here in this
example the ability of the patient to breathe
in and out). Based on the patient's VS, we
see that the respiratory effort is
compromised majorly AND that there is a
risk of inhalation injury since the patient is
coughing up black sooty sputum. Therefore,
the nurse should place the patient in high
Fowler’s position to help with respiratory
effort (unless contraindicated with spinal
injuries), prep the patient for escharotomy
(this will cut the eschar and help relieve
pressure and allow for breathing) and prep
for intubation to help with the respiratory
distress. In addition, obtain IV access in at
least two sites for fluid
replacement….remember the first 24 hours
after a burn a patient is at risk for
hypovolemic shock.
15. A patient arrives to the ER due to
experiencing burns while in an enclosed
warehouse. Which assessment findings
below demonstrate the patient may have
experienced an inhalation injury?
A. Carbonaceous sputum
B. Hair singeing on the head and nose
C. Lhermitte's Sign
D. Bright red lips
E. Hoarse voice
F. Tachycardia
The answers are A, B, D, E, and F. These
are all signs of a possible inhalation injury.
Bright red lips and tachycardia are present
in carbon monoxide poisoning as well.
16. You're providing education to a group of
local firefighters about carbon monoxide
poisoning. Which statement is correct about
the pathophysiology regarding this
condition?
A. "Patients are most likely to present with
cyanosis around the lips and face."
B. "In this condition, carbon monoxide binds
to the hemoglobin of the red blood cell
leading to a decrease in the ability of the
hemoglobin to carry oxygen to the body."
C. "Carbon monoxide poisoning leads to a
hyperoxygenated state, which causes
hypercapnia."
D. "Carbon monoxide binds to the
hemoglobin of the red blood cell and
prevents the transport of carbon dioxide out
of the blood, which leads to poisoning."
The answer is B. This is the only correct
statement about carbon monoxide
poisoning.
17. A patient experienced a full-thickness
burn 72 hours ago. The patient's vital signs
are within normal limits and urinary output is
50 mL/hr. This is known as what phase of
burn management?
A. Emergent
B. Acute
C. Rehabilitative
The answer is B. This phase starts when
capillary permeability has returned to
normal and the patient's vitals are within
normal limits and ends with wound closure.
The phase after this is rehabilitative.
18. What are some patient priorities during
the emergent phase of burn management?
A. Fluid volume
B. Respiratory status
C. Psychosocial
D. Wound closure
E. Nutrition
The answer is A and B. This phase starts
from the onset of the burn and ends with the
restoration of capillary permeability. Wound
closure, and nutrition would be during the
acute phase, and would continue into the
rehabilitative phase. Psychosocial would be
in the rehab phase.
19. During the emergent phase of burn
management, you would expect the
following lab values:
A. Low sodium, low potassium, high
glucose, low hematocrit
B. High sodium, low potassium, low
glucose, high hematocrit
C. High sodium, high potassium, high
glucose, low hematocrit
D. Low sodium, high potassium, high
glucose, high hematocrit
The answer is D. Think about the increase
in the capillary permeability that happens
with severe burns, which causes the plasma
to leave the intravascular system and enter
the interstitial tissue: Low sodium..why:
sodium leaves with the plasma to the
interstitial tissue and drops the levels in the
blood; High potassium...why? damaged
cells lysis and leak potassium which
increases the leave in the blood; high
glucose...why? stress response leads the
liver to release glycogen and this increases
levels; high hematocrit...why? when the
plasma leaves the intravascular system (the
fluid) it causes the blood to become more
concentrated so hematocrit increases (this
will decrease when the patient's fluid is
replaced).
20. A patient is receiving IV Lactated
Ringers 950 mL/hr post 18 hours after a
receiving a severe burn. The patient urinary
output is 20 mL/hr. As the nurse your next
nursing action is to:
A. Increase the IV fluids
B. Continue to monitor the patient
C. Decrease the IV fluids
D. Notify the physician of this finding
The answer is D. The patient's urinary
output is too low and needs more fluids. It
should be at least 30 mL/hr. Therefore, the
nurse must notify the physician for further
orders. The nurse can NOT increase or
decrease IV fluids without a physician's
order.
21. A patient who is being treated for partial
thickness burns on 60% of the body is now
in the acute phase of burn management.
The nurse assesses the patient for a
possible Curling's Ulcer. What signs and
symptoms can present with this condition?
A. Swelling and pain on the area distal to
the burn
B. Burning, gnawing sensation pain in the
stomach and vomiting
C. Dark red or gray sores on the soles of
the feet
D. Difficulty swallowing and gagging
The answer is B. This is a type of ulcer that
occurs in the stomach, duodenum, due to a
high amount of stress on the body from a
burn. The blood supply to the factors that
help protect the stomach lining from gastric
erosion decreases and this allows for ulcers
to form.
22. During the acute phase of burn
management, what is the best diet for a
patient who has experienced severe burns?
A. High fiber, low calories, and low protein
B. High calorie, high protein and
carbohydrate
C. High potassium, high carbohydrate, and
low protein
D. Low sodium, high protein, and restrict
fluids to 1 liter per day
The answer is B. This type of diet promotes
wound healing and meets the caloric
demands of the body.
23. You're assisting the nursing assistant
with repositioning a patient with full-
thickness burns on the neck. Which action
by the nursing assistant requires you to
intervene?
A. The nursing assistant elevates the head
of the bed above 30 degrees.
B. The nursing assistant places a pillow
under the patient's head.
C. The nursing assistant places rolled
towels under the patient's shoulders.
D. The nursing assistant covers the patient
with sterile linens.
The answer is B. If a patient has severe
burns to the neck (head as well) a pillow
should NOT be used under the head
because this can cause wound contractions.
Instead rolled towels should be placed
under the shoulders.
24. A patient has full-thickness burns on the
front and back of both arm and hands. It is
nursing priority to:
A. Elevate and extend the extremities
B. Elevate and flex the extremities
C. Keep extremities below heart level and
extended
D. Keep extremities level with the heart
level and flexed
The answer is A. This position will decrease
edema, which will help prevent
compartment syndrome.
25. A patient has an emergency
escharotomy performed on the right leg.
The patient has full-thickness
circumferential burns on the leg. Which
finding below demonstrates the procedure
was successful?
A. The patient can move the extremity.
B. The right foot's capillary refill is less than
2 seconds.
C. The patient reports a new sensation of
extreme pain.
D. The patient has a positive babinski reflex.
The answer is B. Escharotomy is performed
when a full-thickness burn, due to eschar
(which is burned tissue that is hard), is
compromising blood flow to the distal
extremity. The eschar is cut and this
relieves pressure and allows blood to flow to
the extremity.
26. Your patient with severe burns is due to
have a dressing change. You will pre-
medicate the patient prior to the dressing
change. The patient has standing orders for
all the medications below. Which medication
is best for this patient?
A. IM morphine
B. PO morphine
C. IV morphine
D. Subq morphine
The answer is C. The best route that is
predictable and easily absorbed is via the IV
route in burn victims.
27. After receiving report on a patient
receiving treatment for severe burns, you
perform your head-to-toe assessment. On
arrival to the patient's room you note the
room temperature to be 75'F. You will:
A. Decrease the temperature by 5-10
degrees to prevent hyperthermia.
B. Leave the temperature setting.
C. Increase the temperature to a minimum
of 85'F.
The answer is C. Patients with severe burns
can NOT regulate their temperature and are
at risk for hypothermia. The room
temperature should be a minimum of 85'F.
28. You are about to provide care to a
patient with severe burns. You will don:
A. gloves
B. goggles
C. gown
D. N-95 mask
E. surgical mask
F. shoe covers
G. hair cover
The answer is A, C, E, F, and G. Before
providing care to a patient with severe burns
the nurse would want to wear protective
isolation apparel like: gloves, gown, surgical
mask, shoe covers, and hair cover. This
protects the patient from potential infection.
29. While collecting a medical history on a
patient who experienced a severe burn,
which statement by the patient's family
member requires nursing intervention?
A. "He takes medication for glaucoma".
B. "I think it has been 10 years or more
since he had a tetanus shot."
C. "He was told he had COPD last year."
D. "He smokes 2 packs of cigarettes a day."
The answer is B. Patients who have had
burns need a tetanus shot if they have not
had a vaccine within the past 5 to 10 years.
30. A patient is presenting with bright red
lips, headache, and nausea. The physician
suspects carbon monoxide poisoning. As
the nurse, you know the patient needs:
A. Oxygen nasal cannula 5-6 Liters
B. 100% oxygen via non-rebreather mask
C. Continuous Bipap
D. Venturi mask 6 L oxygen
The answer is B. This is the treatment for
carbon monoxide poisoning.
1. A 25 year old female patient has
sustained burns to the back of the right arm,
posterior trunk, front of the left leg, anterior
head and neck, and perineum. Using the
Rule of Nines, calculate the total body
surface area percentage that is burned?
A. 46%
B. 37%
C. 36%
D. 28%
The answer is B. Back of right arm (4.5%),
posterior trunk (18%), front of left leg (9%),
anterior head and neck (4.5%) and
perineum (1%) which equals 37%.
2. A 68 year old male patient has partial
thickness burns to the front and back of the
right and left leg, front of right arm, and
anterior trunk. Using the Rule of Nines,
calculate the total body surface area
percentage that is burned?
A. 40.5%
B. 49.5%
C. 58.5%
D. 67.5%
The answer is C. Front and back of right
and left leg (36%), front of right arm (4.5%),
anterior trunk (18%) which equals 58.5%.
3. A 35 year old male patient has full
thickness burns to the anterior and posterior
head and neck, front of left leg, and
perineum. Using the Rule of Nines,
calculate the total body surface area
percentage that is burned?
A. 37%
B. 14.5%
C. 29%
D. 19%
The answer is D. Anterior and posterior
head and neck (9%), front of left leg (9%),
perineum (1%) which equals 19%.
4. A 66 year old female patient has deep
partial-thickness burns to both of the legs on
the back, front and back of the trunk, both
arms on the front and back, and front and
back of the head and neck. Using the Rule
of Nines, calculate the total body surface
area percentage that is burned?
A. 72%
B. 63%
C. 81%
D. 45%
The answer is C. Both of the legs on the
back (18%), front and back of the trunk
(36%), both arms on the front and back
(18%), front and back of the head and neck
(9%) which equals 81%.

5. A 58 year old female patient has

superficial partial-thickness burns to the
anterior head and neck, front and back of
the left arm, front of the right arm, posterior
trunk, front and back of the right leg, and
back of the left leg. Using the Rule of Nines,
calculate the total body surface area
percentage that is burned?
A. 63%
B. 81%
C. 72%
D. 54%
The answer is A. Anterior head and neck
(4.5%), front and back of the left arm (9%),
front of the right arm (4.5%), posterior trunk
(18%), front and back of the right leg (18%),
back of the left leg (9%) which equals 63%.

6. A 35 year old male patient has superficial

partial-thickness burns to the anterior right
arm, posterior left leg, and anterior head
and neck. Using the Rule of Nines, calculate
the total body surface area percentage that
1. A 45 year old female patient has
is burned?
superficial partial thickness burns on the
A. 36%
posterior head and neck, front of the left
B. 9%
arm, front and back of the right arm,
C. 18%
posterior trunk, front and back of the left leg,
D. 29%
and back of right leg. The patient weighs 91
The answer is C. Anterior right arm (4.5%),
kg. Use the Parkland Burn Formula to
posterior left leg (9%), and anterior head
calculate the total amount of Lactated
and neck (4.5%) which equals 18%.
Ringers that will be given over the next 24
hours?
A. 22,932 mL
B. 26,208 mL
C. 16,380 mL
D. 12,238 mL
The answer is A: 22,932 mL. Formula: Total
Amount of LR = 4 mL x BSA % x pt's weight
in kg. Pt's weight 91 kg. BSA percentage:
63%... posterior head and neck (4.5%), front
of the left arm (4.5%), front and back of the
right arm (9%), posterior trunk (18%), front
and back of the left leg (18%), back of right
leg (9%) equals: 63%......4 x 63 x 91 =
22,932 mL
2. A 30 year old female patient has deep
partial thickness burns on the back of the
right arm, posterior trunk, front of the left
leg, anterior head and neck, and perineum.
The patient weighs 150 lbs. Use the
Parkland Burn Formula to calculate the total
amount of Lactated Ringers that will be
given over the next 24 hours?
A. 14,960 mL
B. 12,512 mL
C. 10,064 mL
D. 16,896 mL
The answer is C: 10,064 mL Formula: Total
Amount of LR = 4 mL x BSA % x pt's weight
in kg. Pt's weight 150 lbs....convert to
kg....150 divided by 2.2 = 68 kg. BSA
percentage: 37%...Back of right arm (4.5%),
posterior trunk (18%), front of left leg (9%),
anterior head and neck (4.5%) and
perineum (1%) which equals 37%......4 x 37
x 68 = 10,064 mL
3. A 30 year old female patient has deep
partial thickness burns on the front and back
of the right and left leg, front of right arm,
and anterior trunk. The patient weighs 63
kg. Use the Parkland Burn Formula: What is
the flow rate during the FIRST 8 hours
(mL/hr) based on the total you calculated?
A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/hr
D. 789 mL/hr
The answer is A: 921 mL/hr....First calculate
the total amount of fluid needed with the
formula: Total Amount of LR = 4 mL x BSA
% x pt's weight in kg. The pt's weight 63 kg.
BSA percentage: 58.5%...Front and back of
right and left leg (36%), front of right arm
(4.5%), anterior trunk (18%) which equals
58.5%. ......4 x 58.5 x 63 = 14,742
mL......Remember during the FIRST 8 hours
1/2 of the solution is infused, which will be
14,742 divided by 2 = 7371 mL......Hourly
Rate: 7371 divide by 8 equals 921 mL/hr
4. A 59 year old male patient has full
thickness burns on both of the legs on the
back, front and back of the trunk, both arms
on the front and back, and front and back of
the head and neck. The patient weighs 186
lbs. Use the Parkland Burn Formula: You've
already infused fluids during the first 8
hours. Now what will you set the flow rate
during the next 16 hours (mL/hr) based on
the total you calculated?
A. 563 mL/hr
B. 854 mL/hr
C. 289 mL/hr
D. 861 mL/hr
The answer is D: 861 mL/hr First calculate
the total amount of fluid needed with the
formula: Total Amount of LR = 4 mL x BSA
% x pt's weight in kg. The pt's weight 186
lbs...need to convert to kg: 186 divided by
2.2 = 85 kg. BSA percentage: 81%...Both of
the legs on the back (18%), front and back
of the trunk (36%), both arms on the front
and back (18%), front and back of the head
and neck (9%) which equals 81%.......4 x 81
x 85 = 27,540 mL. You've already infused
half of the solution during the first 8
hours...so 13,770 mL is left and it needs to
be infused over 16 hours. Hourly rate:
13,770 mL divided by 16 hours equals 861
mL/hr

5. A 29 year old male patient has superficial
partial thickness burns on the anterior right
arm, posterior left leg, and anterior head
and neck. The patient weighs 78 kg. Use
the Parkland Burn Formula to calculate the
total amount of Lactated Ringers that will be
given over the next 24 hours?
A. 11,232 mL
B. 5,616 mL
C. 2,808 mL
D. 16,848 mL
The answer is B: 5,616 mL. Formula: Total
Amount of LR = 4 mL x BSA % x pt's weight
in kg. Pt's weight 78 kg. BSA percentage:
18%...Anterior right arm (4.5%), posterior
left leg (9%), and anterior head and neck
(4.5%) which equals 18%.....4 x 18 x 78 =
5,616 mL
1. A patient has a potassium level of 9.0.
Which nursing intervention is priority?
A. Prepare the patient for dialysis and place
the patient on a cardiac monitor
B. Administer Spironolactone
C. Place patient on a potassium restrictive
diet
D. Administer a laxative
The answer is A: Prepare the patient for
dialysis and place the patient on a cardiac
monitor
4. Which patient is at risk for hyperkalemia?
A. Patient with Parathyroid cancer
B. Patient with Cushing’s Syndrome
C. Patient with Addison’s Disease
D. Patient with breast cancer
The answer is C: Patient with Addison’s
Disease
3. Tall peaked T-waves, flat P-waves,
prolonged PR intervals and widened QRS
complexes can present in which of the
following conditions?
A. Hypocalemia
B. Hypercalemia
C. Hypokalemia
D. Hyperkalemia
The answer is D: Hyperkalemia
2. Which of the following is not a symptom
of hyperkalemia?
A. Positive Chvostek’s sign
B. Decreased blood pressure
C. Muscle twitches/cramps
D. Weak and slow heart rate
The answer is A: Positive Chvostek’s sign
6. A patient with nasogastric suctioning is
experiencing diarrhea. The patient is
ordered a morning dose of Lasix 20mg IV.
Patient’s potassium level is 3.0. What is
your next nursing intervention?
A. Hold the dose of Lasix and notify the
doctor for further orders
B. Administered the Lasix and notify the
doctor for further orders
C. Turn off the nasogastric suctioning and
administered a laxative
D. No intervention is need the potassium
level is within normal range
The answer is A: Hold the dose of Lasix and
notify the doctor for further orders
5. A patient’s potassium level is 3.0. Which
foods would you encourage the patient to
consume?
A. Cheese, collard greens, and fish
B. Avocados, strawberries, and potatoes
C. Tofu, oatmeal, and peas
D. Peanuts, bread, and corn
The answer is B: Avocados, strawberries,
and potatoes
7. A patient is presenting with an orthostatic
blood pressure of 80/40 when she stands
up, thready and weak pulse of 58, and
shallow respirations. In addition, the patient
has been having frequent episodes of
vomiting and nausea and is taking
hydrochlorothiazide. Which of the following
findings would explain the patient’s
condition?
A. Potassium level of 7.0
B. Potassium level of 3.5
C. Potassium level of 2.4
D. None of the options are correct
The answer is C: Potassium level of 2.4
8. Which patient is at a potential risk for
Digoxin toxicity?
A. A patient with Cushing’s syndrome taking
Laxis 20 mg IV twice a day
B. A patient with a calcium level of 8.9
C. A patient with a potassium level of 3.8
D. A patient presenting with painful muscle
spasms and positive Trousseau’s sign
The answer is A: A patient with Cushing’s
syndrome taking Laxis 20 mg IV twice a day
9. Which of the following is indicative of an
EKG change in a case of hypokalemia?
A. Widened QRS complex and prolonged
PR interval
B. Prolonged ST interval and Widened T-
wave
C. Tall T-waves and depressed ST segment
D. ST depression and inverted T-wave
The answer is D: ST depression and
inverted T-wave
9. A patient has a potassium level of 2.0.
What would you expect to be ordered for
this patient?
A. Potassium 30 meq IV push
B. Infusion of Potassium intravenously
C. An oral supplement of potassium
D. Intramuscular injection of Potassium
The answer is B: Infusion of Potassium
intravenously
Nurse Ejay is assigned to telephone triage.
A client called who was stung by a
honeybee and is asking for help. The client
reports pain and localized swelling but has
no respiratory distress or other symptoms of
anaphylactic shock. What is the appropriate
initial action that the nurse should direct the
client to perform?
A. Removing the stinger by scraping it
B. Applying a cold compress
C. Taking an oral antihistamine
D. Calling 911
Correct
Correct Answer: A. Removing the stinger by
scraping it.
Since the stinger will continue to release
venom into the skin, removing the stinger
should be the first action that the nurse
should direct to the client. Within the first
few minutes after the sting, the stinger
should be removed via scraping with a
credit card rather than squeezing/tweezing
to avoid further venom exposure.
Option B: Uncomplicated local reactions can
be treated with supportive care (ice packs,
NSAIDs/APAP for pain, H1/H2 blocker).
Cold compress follows the administration of
antihistamine. Large local reactions should
also be treated with supportive care along
with glucocorticoids (usually a burst course
of prednisone 40 to 60 mg per day for 3 to 5
days) to decrease the inflammatory
response and improve symptoms.
Option C: After removing the stinger, an
antihistamine is administered. H1 and H2
antagonists block the effects of histamine
decreasing pruritus, erythema, and urticaria.
Corticosteroids (prednisone,
methylprednisolone, dexamethasone) act to
decrease inflammation and immune
response to the antigen.
Option D: The caller should be further
advised about symptoms that require 911
assistance. Systemic reactions
(anaphylaxis) are life-threatening and
should be managed as such. ABCs first.
The airway can be lost within seconds to
minutes, so intubate early. As with any
anaphylactic reaction, epinephrine,
corticosteroids, H1 and H2 antagonists, and
intravenous (IV) fluids should be given
immediately.
2. Question
Nurse Anna is an experienced travel nurse
who was recently employed and is assigned
to the emergency unit. In her first week of
the job, which of the following area is the
most appropriate assignment for her?
A. Triage
B. Ambulatory section
C. Trauma team
D. Psychiatric care
Correct
Correct Answer: B. Ambulatory section
The ambulatory section deals with clients
with relatively stable conditions. The
decision of whether or not to delegate or
assign is based upon the RN’s judgment
concerning the condition of the patient, the
competence of all members of the nursing
team and the degree of supervision that will
be required of the RN if a task is delegated.
Option A: The RN delegates only those
tasks for which he or she believes the other
health care worker has the knowledge and
skill to perform, taking into consideration
training, cultural competence, experience
and facility/agency policies and procedures.
Option C: This area should be filled with
nurses who are experienced with hospital
routines and policies and have the ability to
locate equipment immediately. There is both
individual accountability and organizational
accountability for delegation. Organizational
accountability for delegation relates to
providing sufficient resources, including
sufficient staffing with an appropriate staff
mix.
Option D: Few places are more hectic than
a Hospital Emergency Room. Clearly,
delegating important nursing tasks is the
only plausible way for short-staffed
emergency rooms to meet the challenges of
providing quality patient care. All decisions
related to delegation and assignment are
based on the fundamental principles of
protection of the health, safety, and welfare
of the public.”
3. Question
A client arrives at the emergency
department who suffered multiple injuries
from a head-on car collision. Which of the
following assessment should take the
highest priority to take?
A. Unequal pupils
B. Irregular pulse
C. Ecchymosis in the flank area
D. A deviated trachea
Correct
Correct Answer: D. A deviated trachea
A deviated trachea is a symptom of tension
pneumothorax, which will result in
respiratory distress if left untreated. The first
question in the ESI triage algorithm for
triage nurses asks whether “the patient
requires immediate life-saving interventions”
or simply “is the patient dying?” The nurse
determines this by looking to see if the
patient has a patent airway, if the patient is
breathing, and does the patient has a pulse.
Option A: Another scale used by nurses in
the assessment is if the patient is meeting
criteria for a true level 1 trauma is the AVPU
(alert, verbal, pain, unresponsive) scale.
The scale is used to evaluate if the patient
had a recent or sudden change in the level
of consciousness and needs immediate
intervention.
Option B: The nurse evaluates the patient,
checking pulse, rhythm, rate, and airway
patency. Is there concern for inadequate
oxygenation? Is this person
hemodynamically stable? Does the patient
need any immediate medication or
interventions to replace volume or blood
loss? Does this patient have pulselessness,
apnea, severe respiratory distress, oxygen
saturation below 90, acute mental status
changes, or unresponsiveness?
Option C: If the patient is not categorized as
a level 1, the nurse then decides if the
patient should wait or not. This is
determined by three questions; is the
patient in a high-risk situation, confused,
lethargic, or disoriented? Or is the patient in
severe pain or distress? The high-risk
patient is one who could easily deteriorate,
one who could have a threat to life, limb, or
organ.
4. Question
Nurse Kelly, a triage nurse encountered a
client who complained of mid-sternal chest
pain, dizziness, and diaphoresis. Which of
the following nursing action should take
priority?
A. Administer oxygen therapy via nasal
cannula
B. Notify the physician
C. Complete history taking
D. Put the client on ECG monitoring
Correct
Correct Answer: A. Administer oxygen
therapy via nasal cannula.
The priority goal is to increase myocardial
oxygenation. Place the patient on a cardiac
monitor, establish intravascular access (IV)
access, give 162 mg to 325 mg chewable
aspirin, clopidogrel, or ticagrelor (unless
bypass surgery is imminent), control pain
and consider oxygen (O2) therapy.
Option B: Patients with non-ST elevation
myocardial infarction (NSTEMI) and
unstable angina should be admitted for
cardiology consultation and workup.
Patients with stable angina may be
appropriate for outpatient workup.
Option C: Carefully review the patient’s
medical history for cardiac history,
coagulopathies, and kidney disease. Ask
about family history, especially cardiac, and
ask about social histories like drug use and
tobacco use.
Option D: These actions are also
appropriate and should be performed
immediately. Electrocardiogram (ECG)
preferably in the first 10 min of arrival,
(consider serial ECGs). Patients with ST-
elevation on ECG patients should receive
immediate reperfusion therapy either
pharmacologic (thrombolytics) or transfer to
the catheterization laboratory for
percutaneous coronary intervention (PCI).
5. Question
A group of people arrived at the emergency
unit by a private car with complaints of
periorbital swelling, cough, and tightness in
the throat. There is a strong odor emanating
from their clothes. They report exposure to
a “gas bomb” that was set off in the house.
What is the priority action?
A. Instruct personnel to don personal
protective equipment
B. Direct the clients to the cold or clean
zone for immediate treatment
C. Immediately remove other clients and
visitors from the area
D. Measure vital signs and auscultate lung
sounds
E. Direct the clients to the decontamination
area
Correct
Correct Answer: E. Direct the clients to the
decontamination area.
Decontamination in a specified area is the
priority. The decontamination and support
areas are established within the Warm
Zone, also referred to as the Contamination
Reduction Zone. Decontamination involves
thorough washing to remove contaminants.
Option A: Personnel should don personal
protective equipment before assisting with
decontamination or assessing the clients.
Take precautionary measures to preserve
the health and safety of emergency
responders working within the
Contamination Reduction (Warm) Zone and
the Exclusion (Hot) Zone. This includes
ensuring responders wear appropriate
personal protective equipment (PPE).
Option B: The clients must undergo
decontamination before entering cold or
clean areas. In mass casualty incidents,
decontamination corridors can be set up
that consist of high volume, low-pressure
water deluges. Assign personnel to
decontamination stations to control and
instruct victims when they enter the
decontamination area.
Option C: Decontamination triage is
especially important in mass casualty
incidents and should not be confused with
medical triage. Decontamination triage is
the process of determining which victims
require decontamination and which do not.
Rapidly identifying victims who may not
require decontamination can significantly
reduce the time and resources needed for
mass decontamination.
Option D: Set up or assign an area or
building as a safe refuge/observation area
for victims who do not require medical
attention. Here they can be monitored for a
delayed outbreak of symptoms or
indications of residual contamination.
6. Question
When an unexpected death occurs in the
emergency department, which task is the
most appropriate to delegate to a nursing
assistant?
A. Assisting with postmortem care
B. Facilitate meetings between the family
and the organ donor specialist
C. Escorting the family to a place of privacy
D. Help the family to collect belongings
Correct
Correct Answer: A. Assisting with
postmortem care.
Postmortem care requires some turning,
cleaning, lifting, and so on, and the nursing
assistant is able to assist with these duties.
The use of NAPs increasingly demands
registered nurses to delegate patient care
tasks according to the principles of the ANA.
These principles define nursing delegation
as the “transfer of responsibility for the
performance of an activity from one
individual to another while retaining
accountability for the outcome.”
Option B: The RN may delegate
components of care, but does not delegate
the nursing process itself. The practice of
pervasive functions of assessment,
planning, evaluation, and nursing judgment
cannot be delegated. The decision of
whether or not to delegate or assign is
based upon the RN’s judgment concerning
the condition of the patient, the competence
of all members of the nursing team, and the
degree of supervision that will be required of
the RN if a task is delegated.
Option C: A licensed nurse should take
responsibility for the other tasks to help the
family begin the grieving process. The RN
delegates only those tasks for which he or
she believes the other health care worker
has the knowledge and skill to perform,
taking into consideration training, cultural
competence, experience, and
facility/agency policies and procedures.
Option D: In cases of questionable death,
belongings may be retained for evidence, so
the chain of custody would have to be
maintained. The registered nurse
individualized communication regarding the
delegation to the nursing assistive
personnel and client situation and the
communication should be clear, concise,
correct, and complete. The registered nurse
verifies comprehension with the nursing
assistive personnel and that the assistant
accepts the delegation and the
responsibility that accompanies it.
7. Question
The physician has ordered cooling
measures for a child with a fever who is
likely to be discharged when the
temperature comes down. Which task would
be appropriate to delegate to a nursing
assistant?
A. Prepare and administer a tepid sponge
bath
B. Explain the need for giving cool fluids
C. Assist the child in removing outer
clothing
D. Advise the parent to use acetaminophen
(Tylenol) instead of aspirin
Correct
Correct Answer: C. Assist the child in
removing outer clothing.
The nursing assistant can help with the
removal of outer clothing, which allows the
heat to dissipate from the child’s skin. The
client is the center of care. The needs of the
client must be competently met with the
knowledge, skills and abilities of the staff to
meet these needs. In other words, the nurse
who delegates aspects of care to other
members of the nursing team must balance
the needs of the client with the abilities of
those to which the nurse is delegating tasks
and aspects of care, among other things
such as the scopes of practice and the
policies and procedures within the particular
healthcare facility.
Option A: Tepid baths are not usually given
because of the possibility of shivering and
rebound. Registered nurses who assign,
delegate, and/or provide nursing care to
clients and groups of clients must report all
significant changes that occur in terms of
the client and their condition. For example,
a significant change in a client’s laboratory
values requires that the registered nurse
report this to the nurse’s supervisor and
doctor.
Option B: Explaining is a teaching function
only appropriate for a registered nurse. The
staff members’ levels of education,
knowledge, past experiences, skills,
abilities, and competencies are also
evaluated and matched with the needs of all
of the patients in the group of patients that
will be cared for.
Option D: Advising is a teaching function
that is the responsibility of the registered
nurse. Delegation should be done according
to the differentiated practice for each of the
staff members. A patient care technician, a
certified nursing assistant, a licensed
practical nurse, an associate degree
registered nurse, and a bachelor’s degree
registered nurse should not be delegated to
the same aspects of nursing care.
8. Question
You are preparing a child for IV conscious
sedation before the repair of a facial
laceration. What information should you
report immediately to the physician?
A. The child suddenly pulls out the IV
B. The parent is not sure regarding the
child's tetanus immunization status
C. The parent wants information about the
IV conscious sedation
D. The parent's refusal of the
administration of the IV sedation
Correct
Correct Answer: D. The parent’s refusal of
the administration of the IV sedation.
The refusal of the parents is an absolute
contraindication; therefore the physician
must be notified. But the autonomy of
parents is very obviously different from the
autonomy of patients to make decisions for
themselves. While adult patients are
generally thought to have an absolute right
to refuse medical treatment for themselves,
we don’t usually think that parents can
refuse all medical treatment for their
children.
Option A: The RN can reestablish the IV
access. Parents’ views might, at least in
some circumstances, influence whether or
not treatment would be in a child’s best
interests. Nurses and doctors are able to
administer fluid directly into the veins using
IV therapy. IV therapy is a relatively simple
process that can be performed by nurses,
but there are serious complications
associated with it.
Option B: Tetanus status can be addressed
later. Tetanus immunization is part of the
DTaP (diphtheria, tetanus, and acellular
pertussis) vaccinations. Kids usually get: a
series of four doses of DTaP vaccine before
2 years of age. another dose at 4–6 years of
age.
Option C: The RN can provide information
about conscious sedation. Identifying
teachable moments in clinical practice is an
effective way to increase workplace learning
with all nurses playing a role, not just nurse
educators.
9. Question
The emergency medical service has
transported a client with severe chest pain.
As the client is being transferred to the
emergency stretcher, you note
unresponsiveness, cessation of breathing,
and unpalpable pulse. Which of the
following task is appropriate to delegate to
the nursing assistant?
A. Assisting with the intubation
B. Placing the defibrillator pads
C. Doing chest compressions
D. Initiating bag valve mask ventilation
Correct
Correct Answer: C. Doing chest
compressions.
Performing chest compressions are within
the training of a nurse assistant. Every good
certified nursing assistant should be
proficient at cardiopulmonary resuscitation
(CPR). Basic Life Support (BLS) certification
is the widely-used term for any form of CPR
certification and is required for all
Registered Nurses (RN) and Certified
Nursing Assistants (CNA).
Option A: Due to the nature of critical care
patients it is inevitable that nurses working
in this setting will be called on to assist with
tracheal intubation. This assistant role
requires a high degree of knowledge and
skills in order for the intubation procedure to
be executed smoothly.
Option B: The defibrillator pads are clearly
marked; however placement should be
done by the RN or physician because of the
potential for skin damage and electrical
arcing. Most hospital nurses will be trained
in advisory defibrillation, while a few will be
trained in manual defibrillation.
Option C: The use of the bag valve mask
requires practice, and usually a respiratory
therapist will perform the function. Bag-
valve-mask ventilation can be done with one
person or two, but two-person BVM
ventilation is easier and more effective
because a tight seal must be achieved and
this usually requires two hands on the
mask.
10. Question
The nursing manager decides to form a
committee to address the issue of violence
against ED personnel. Which combination
of employees would be best suited to fulfill
this assignment?
A. ED physicians and charge nurses
B. RNs, LPNs, and nursing assistants
C. Experienced RNs and experienced
paramedics
D. At least one representative from each
group of ED personnel
Incorrect
Correct Answer: D. At least one
representative from each group of ED
personnel.
At least one representative from each group
of ED personnel should be included
because all employees are potential targets
for violence in the ED. The diversity of the
group should also be considered and
assure that each department or each
employee is represented.
Option A: The policies against violence in
the workplace must be developed by
management and employee
representatives, including the health and
safety committee or representative, and
union, if present.
Option B: Administrative practices may also
include education and training for
employees. This education and training
would include not only information about the
workplace’s policy and process to respond
to incidents, but may also include how to
respond to an incident of violence (e.g.,
emergency response, when to contact
security or police, etc.).
Option C: Preventive measures generally
fall into three categories, workplace design,
administrative practices, and work practices.
All employees should know how to respond
to customers or members of the public who
may be angry or frustrated, such as how to
de-escalate a conflict.
11. Question
A client suffered an amputation of the first
and second digits in a chainsaw accident.
Which task should be delegated to an
LPN/LVN?
A. Cleansing the amputated digits and
placing them directly into an ice slurry
B. Wrapping the cleansed digits in saline-
moistened gauze, sealing in a plastic
container, and placing it in icy water
C. Gently cleansing the amputated digits
and the hand with povidone-iodine
 D. Cleansing the digits with sterile normal
saline and placing it in a sterile cup with
sterile normal saline
Incorrect
Correct Answer: B. Wrapping the cleansed
digits in saline-moistened gauze, sealing in
a plastic container, and placing it in icy
water.
Once a finger amputation has occurred,
ischemic tolerance times are 12 hours if
warm and up to 24 hours if cold. For more
proximal amputations, these times are
halved. The amputated part should be
covered in a normal saline-soaked gauze,
sealed in a plastic bag, and submerged in
icy water with no direct contact with ice. If
there is direct contact with ice, it could result
in tissue damage and render the amputated
part non-viable.
Option A: The client is the center of care.
The needs of the client must be competently
met with the knowledge, skills, and abilities
of the staff to meet these needs. In other
words, the nurse who delegates aspects of
care to other members of the nursing team
must balance the needs of the client with
the abilities of those to which the nurse is
delegating tasks and aspects of care,
among other things such as the scopes of
practice and the policies and procedures
within the particular healthcare facility.
Option C: Based on these characteristics
and the total client needs for the group of
clients that the registered nurse is
responsible and accountable for, the
registered nurse determines and analyzes
all of the health care needs for a group of
clients; the registered nurse delegates care
that matches the skills of the person that the
nurse is delegating to.
Option D: The job of the registered nurse is
far from done after client care has been
delegated to members of the nursing team.
The delegated care must be followed up on
and the staff members have to be
supervised as they deliver care. The
registered nurse remains responsible for
and accountable for the quality,
appropriateness, completeness, and
timeliness of all of the care that is delivered.
12. Question
A client arrives in the emergency unit and
reports that a concentrated household
cleaner was splashed in both eyes. Which
of the following nursing actions is a priority?
A. Examine the client's visual acuity
B. Patch the eye
C. Use Restasis (Allergan) drops in the eye
D. Flush the eye repeatedly using sterile
normal saline
Correct
Correct Answer: D. Flush the eye
repeatedly using sterile normal saline.
Initial emergency action during a chemical
splash to the eye includes immediate
continuous irrigation of the affected eye with
normal saline. Immediate irrigation with
copious amounts of an isotonic solution as
described previously is the mainstay of
treatment for chemical burns. Never use
any substance to neutralize chemical
exposure as the exothermic reaction can
lead to secondary thermal injuries.
Option A: After irrigation, visual acuity then
is assessed. Irrigation should continue until
the pH of the eye is between 7.0 to 7.4 and
remains within this range for at least 30
minutes after the irrigation has been
discontinued.
Option B: Patching the eye is not part of the
first-line treatment of a chemical splash.
Irrigation should be gentle, and care should
be taken to avoid direct irrigation to the
cornea to prevent further injury. Use of a
commercial irrigation lens such as a Morgan
lens may be helpful.
Option C: Restasis (Allergan) drops are
used to treat dry eyes. A topical anesthetic
such as tetracaine can be applied directly to
the eye, or 10 mL of 1% lidocaine can be
added to a liter of irrigating fluid, taking care
not to reach a toxic dose if copious irrigation
is required.
13. Question
A client was brought to the emergency
department after suffering a closed head
injury and lacerations around the face due
to a hit-run accident. The client is
unconscious and has a minimal response to
noxious stimuli. Which of the following
assessment findings if observed after few
hours, should be reported to the physician
immediately?
A. Drainage of a clear fluid from the client's
nose
B. Withdrawal of the client in response to
painful stimuli
C. Bruises and minimal edema of the
eyelids
D. Bleeding around the lacerations
Correct
Correct Answer: A. Drainage of a clear fluid
from the client’s nose
Option A: Clear drainage from the client’s
nose indicates that there is a leakage of
CSF and should be reported to the
physician immediately.
14. Question
A 5-year-old client was admitted to the
emergency unit due to the ingestion of an
unknown amount of chewable vitamins for
children at an unknown time. Upon
assessment, the child is alert and with no
symptoms. Which of the following
information should be reported to the
physician immediately?
A. The child was nauseated and vomited
once at home
B. The child has been treated several times
for toxic substance ingestion
C. The vitamin that was ingested contains
iron
D. The child has been treated multiple
times for injuries caused by accidents
Incorrect
Correct Answer: C. The vitamin that was
ingested contains iron.
Iron is a toxic substance that can lead to
massive hemorrhage, shock, coma, and
kidney failure. Iron poisoning is one of the
most common toxic ingestion and one of the
most deadly among children. Failure to
diagnose and treat iron poisoning can have
serious consequences including multi-organ
failure and death.
Option A: During the first stage (0.5 to 6
hours), the patient mainly exhibits
gastrointestinal (GI) symptoms including
abdominal pain, vomiting, diarrhea,
hematemesis, and hematochezia. The
second stage (6 to 24 hours) represents an
apparent recovery phase, as the patient’s
GI symptoms may resolve despite toxic
amounts of iron absorption.
Option B: Patients who have GI symptoms
that resolve after a short period of time and
have normal vital signs require supportive
care and an observation period, as it may
represent the second stage of iron toxicity.
Patients who remain asymptomatic 4 to 6
hours after ingestion or those who have not
ingested a potentially toxic amount do not
require any treatment for iron toxicity.
Option D: This information needs further
investigation but will not change the
immediate diagnostic testing or treatment
plan. Patients who have GI symptoms that
resolve after a short period of time and have
normal vital signs require supportive care
and an observation period, as it may
represent the second stage of iron toxicity.
15. Question
The following clients come to the
emergency department complaining of
acute abdominal pain. Prioritize them for
care in order of the severity of the
conditions.
A 59-year-old man with a pulsating
abdominal mass and sudden onset of
persistent abdominal or back pain, which
can be described as a tearing sensation
within the past hour.
A 27-year-old woman complaining of
lightheadedness and severe sharp left lower
quadrant pain who reports she is possibly
pregnant.
A 15-year-old boy with a low-grade fever,
right lower quadrant pain, vomiting, nausea,
and loss of appetite for the past few days.
A 43-year-old woman with moderate right
upper quadrant pain who has vomited small
amounts of yellow bile and whose
symptoms have worsened over the week.
A 57-year-old woman who complains of a
sore throat and gnawing midepigastric pain
that is worse between meals and during the
night.
Incorrect
The correct order is shown above.
Rationale:
The client with a pulsating mass has an
abdominal aneurysm that may rupture and
he may decompensate easily. An abdominal
aortic aneurysm is a life-threatening
condition that requires monitoring or
treatment depending upon the size of the
aneurysm and/or symptomatology.
The woman with lower left quadrant pain is
at risk for a life-threatening ectopic
pregnancy. An ectopic pregnancy occurs
when fetal tissue implants outside of the
uterus or attaches to an abnormal or
scarred portion of the uterus. Ectopic
pregnancies carry high rates of morbidity
and mortality if not recognized and treated
promptly.
The 15-year-old boy needs evaluation to
rule out appendicitis. It should be
considered in any patient with acute
abdominal pain without a prior
appendectomy. The diagnosis must be
made as quickly as possible because with
time, the rate of rupture increases.
The woman with vomiting needs evaluation
for gallbladder problems, which appear to
be worsening. Disruption of the
gallbladder’s normal physiology can result in
a significant medical burden. Over 20 million
Americans suffer from gallbladder disease
and cholecystectomy is one of the most
common surgeries performed.
Lastly, the woman with mid-epigastric pain
is suffering from an ulcer, but follow-up
diagnostic testing can be scheduled with a
primary care provider. It is important to
understand this disease process is both
preventable and treatable. Patients may be
treated differently depending on the etiology
of their gastric ulcer.
16. Question
The following clients are presented with
signs and symptoms of heat-related illness.
Which of them needs to be attended first?
A. A relatively healthy homemaker who
reports that the air conditioner has been
broken for days and who manifest fatigue,
hypotension, tachypnea, and profuse
sweating.
 B. An elderly person who complains of
dizziness and syncope after standing in the
sun for several hours to view a parade.
C. A homeless person who is a poor
historian; has altered mental status, poor
muscle coordination, and hot, dry ashen
skin; and whose duration of heat exposure
is unknown.
D. A marathon runner who complains of
severe leg cramps and nausea, and
manifests weakness, pallor, diaphoresis,
and tachycardia.
Correct
Correct Answer: C. A homeless person who
is a poor historian; has altered mental
status, poor muscle coordination, and hot,
dry ashen skin; and whose duration of heat
exposure is unknown.
The signs and symptoms manifested by the
homeless person indicate that a heat stroke
is happening, a medical emergency, which
can lead to brain damage. Also, there must
be clinical signs of central nervous system
dysfunction that may include ataxia,
delirium, or seizures, in the setting of
exposure to hot weather or strenuous
physical exertion. Patients who present with
heat stroke typically have vital sign
abnormalities to include an elevated core
body temperature, sinus tachycardia,
tachypnea, a widened pulse pressure, and a
quarter of patients will be hypotensive.
Option A: The homemaker is experiencing
heat exhaustion, which can be managed by
fluids and cooling measures. It is important
to differentiate where the patient is on the
heat illness continuum. The signs and
symptoms of heat exhaustion may present
similarly include cramping, fatigue,
dizziness, nausea, vomiting, headache. If
progression to end-organ damage occurs it
then becomes heat injury.
Option B: The elderly client is at risk for heat
syncope and should be advised to rest in a
cool area and avoid similar situations. Heat
syncope is the temporary, self-limited
dizziness, weakness, or loss of
consciousness during prolonged standing or
positional changes in a hot environment,
including physical activity. The thinking is
that it is due to a combination of
dehydration, pooling of blood in the venous
system, decreased cardiac filling, and low
blood pressure, which leads to decreased
cerebral blood flow.
Option D: The runner is experiencing heat
cramps, which can be managed with fluid
and rest. Heat cramps: include involuntary
spasmodic contractions of large muscle
groups as opposed to an isolated muscle
spasm/cramp that can also occur during or
after exertion. This condition is due to a
relative deficiency of sodium, potassium,
chloride, or magnesium. Other symptoms
may include nausea, vomiting, fatigue,
weakness, sweating, and tachycardia.
17. Question
An anxious female client complains of chest
tightness, tingling sensations, and
palpitations. Deep, rapid breathing, and
carpal spasms are noted. Which of the
following priority action should the nurse do
first?
A. Provide oxygen therapy
B. Notify the physician immediately
C. Administer anxiolytic medication as
ordered
D. Have the client breathe into a brown
paper bag
Incorrect
Correct Answer: D. Have the client breathe
into a brown paper bag
The client is suffering from hyperventilation
secondary to anxiety, the initial action is to
let the client breathe in a paper bag that will
allow the rebreathing of carbon dioxide. The
idea behind breathing into a paper bag or
mask is that rebreathing exhaled air helps
the body put CO2 back into the blood.
Option A: Acute anxiety may require
treatment with a benzodiazepine. Chronic
anxiety treatment consists of
psychotherapy, pharmacotherapy, or a
combination of both. Anxiety disorders
appear to be caused by an interaction of
biopsychosocial factors. Genetic
vulnerability interacts with situations that are
stressful or traumatic to produce clinically
significant syndromes.
Option B: Anxiety is one of the most
common psychiatric disorders but the true
prevalence is not known as many people do
not seek help or clinicians fail to make the
diagnosis. Anxiety is one of the most
common psychiatric disorders in the general
population. Specific phobia is the most
common with a 12-month prevalence rate of
12.1%. Social anxiety disorder is the next
most common, with a 12-month prevalence
rate of 7.4%.
Option C: Selective serotonin reuptake
inhibitors (SSRIs), serotonin-norepinephrine
reuptake inhibitors (SNRIs),
benzodiazepines, tricyclic antidepressants,
mild tranquilizers, and beta-blockers treat
anxiety disorders.
18. Question
An intoxicated client comes into the
emergency unit with uncooperative
behavior, mild confusion, and slurred
speech. The client is unable to provide a
good history but he verbalizes that he has
been drinking a lot. Which of the following is
a priority action of the nurse?
A. Administer IV fluid incorporated with
Vitamin B1 as ordered
B. Administer Naloxone (Narcan) 4 mg as
ordered
C. Contact the family to get information
about the client
D. Obtain an order for the determination of
blood alcohol level
Incorrect
Correct Answer: A. Administer IV fluid
incorporated with Vitamin B1 as ordered.
The client has symptoms of alcohol abuse
and there is a risk for Wernicke syndrome,
which is caused by a deficiency in Vitamin
B. Thiamine deficiency (vitamin B1) is
common in patients with alcohol
dependence. Cognitive impairments may be
an early consequence of thiamine
deficiency. Wernicke’s encephalopathy is
underdiagnosed and undertreated.
Option B: Multiple drug abuse is not
uncommon; however, there is currently
nothing to suggest an opiate overdose that
requires the administration of naloxone.
Naloxone is indicated for the treatment of
opioid toxicity, specifically to reverse
respiratory depression from opioid use. It is
useful in accidental or intentional overdose
and acute or chronic toxicity.
Option C: Teens and young adults are at
higher risk for binge drinking, which can
cause alcohol poisoning. Binge drinking is a
pattern of drinking that raises the blood
alcohol level within a short period of time.
Though it varies from person to person,
binge drinking is usually defined as four
drinks for women and five drinks for men in
a two-hour period.
Option D: Additional information or the
results of the blood alcohol testing are part
of the management but should not delay the
immediate treatment. A blood alcohol test
may be used to find out if the patient has
alcohol poisoning, a life-threatening
condition that happens when your blood
alcohol level gets very high. Alcohol
poisoning can seriously affect basic body
functions, including breathing, heart rate,
and temperature.
19. Question
A nurse is providing discharge instructions
to a woman who has been treated for
contusions and bruises due to domestic
violence. What is the priority intervention for
this client?
A. Arranging transportation to a safe house
B. Advising the client about contacting the
police
C. Making an appointment to follow up on
the injuries
D. Making a referral to a counselor
Incorrect
Correct Answer: A. Arranging transportation
to a safe house.
Safety is a priority for this client and she
should not return to a place where violence
could recur. Make sure a safe environment
is provided. Offer shelter options, legal
services, counseling, and facilitate such
referral.
Option B: If the patient does not want to go
to a shelter, provide telephone numbers for
domestic violence or crisis hotlines and
support services for potential later use.
Provide the patient with instructions but be
mindful that written materials may pose a
danger once the patient returns home.
Option C: Without proper social service and
mental health intervention, all forms of
abuse can be recurrent and escalating
problems, and the prognosis for recovery is
poor. Without treatment, domestic and
family violence usually recurs and escalates
in both frequency and severity.
Option D: These are important for the long-
term management of this case. Health
professionals provide an opportunity for
victims of domestic violence to obtain help.
Of those injured by domestic violence, over
75% continue to experience abuse. Over
half of battered women who attempt suicide
will try again; often they are successful with
the second attempt.
20. Question
In the work setting, what is the primary
responsibility of the nurse in preparation for
disaster management, that includes natural
disasters and bioterrorism incidents?
A. Being aware of the signs and symptoms
of potential agents of bioterrorism
B. Making ethical decisions regarding
exposing self to potentially lethal
substances
C. Being aware of the agency's emergency
response plan
D. Being aware of what and how to report
to the Centers for Disease Control and
Prevention
Correct
Correct Answer: C. Being aware of the
agency’s emergency response plan.
In disaster preparedness, the nurse should
know the emergency response plan. This
gives guidance that includes the roles of the
team members, responsibilities, and
mechanisms of reporting. Emergency
preparedness encompasses diverse fields
within the hospital and regional settings.
Planning membership groups should
address key aspects across these fields
including but not limited to: public safety,
facilities, logistics, pharmacy, transportation,
clinical patient care, non-clinical patient
care, media/public relations,
communications, radiation, infection control,
and administration.

Option A: Planning/Prevention focuses on
providing protection from disasters on both
the domestic and international levels in an
attempt to limit the loss of life and reduce
the financial impact of disaster response.
Planning includes care, evacuation, and
environmental planning and response
standards.
Option B: Risk Assessment identifies high
priority and vulnerability areas and directs
mitigation efforts. The goal of risk
assessment is the identification of the
possible disasters that challenge the area
including both internal and external
disasters, collecting resource inventory,
identifying a facility or region’s
vulnerabilities based on location and
resources, and generating a priorities list.
Option D: The Centers for Disease Control
and Prevention (CDC) provides education
and information regarding specific disaster
types, including infectious diseases,
chemical and radiation exposure, and
natural disaster or weather-related
incidents.
1. A patient is admitted with a chest wound
and experiencing extreme dyspnea,
tachycardia, and hypoxia. The chest wound
is located on the left mid-axillary area of the
chest. On assessment, you note there is
unequal rise and fall of the chest with
absent breath sounds on the left side. You
also note a "sucking" sound when the
patient inhales and exhales. The patient's
chest x-ray shows a pneumothorax. What
type of pneumothorax is this known as?
A. Closed pneumothorax
B. Open pneumothorax
C. Tension pneumothorax
D. Spontaneous pneumothorax
The answer is B. This description is of an
open pneumothorax. An open
pneumothorax happens when there is an
opening in the chest wall ( from a gun shot,
stabbing etc.) that creates a passage
between the outside air and intrapleural
space. This allow air to pass back and forth
during inspiration and expiration. The body
will shunt air through the opening in the
chest well instead of the trachea (if the
opening on the chest is large enough) which
will create a "sucking" sound.
2. In regards to the patient in the question
above, which of the following options below
is a nursing intervention you would provide
to this patient?
A. Place the patient in supine position
B. Place a non-occlusive dressing over the
chest wound
C. Place a sterile occlusive dressing over
the chest wound and tape it on three sides
D. Prepare the patient for a thoracentesis
The answer is C. The nursing intervention
would be to place a sterile occlusive
dressing over the wound and tape it on 3
sides (leaving one side NOT taped). This
will allow exhaled air to leave the opening
but seal over the opening when inhaling
(hence not letting pressure build in the
intrapleural space and prevent a tension
pneumothorax).
3. A patient is diagnosed with a primary
spontaneous pneumothorax. Which of the
following is NOT a correct statement about
this type of pneumothorax?
A. It can be caused by the rupture of a
pulmonary bleb.
B. It can occur in patients who are young,
tall and thin without a history of lung
disease.
C. Smoking increases the chances of a
patient developing a spontaneous
pneumothorax.
D. It is most likely to occur in patients with
COPD, asthma, and cystic fibrosis.
The answer is D. All options are correct
about primary spontaneous pneumothorax
EXCEPT D. This describes SECONDARY
spontaneous pneumothorax not primary.
4. Which of the following is a LATE sign of
the development of a tension
pneumothorax?
A. Hypotension
B. Tachycardia
C. Tracheal deviation
D. Dyspnea
The answer is C. With a tension
pneumothorax, you will quickly see
hypotension, tachycardia, and dyspnea as
the mediastinum shifts from the extra
pressure in the intrapleural space on the
affected side. A late sign of a tension
pneumothorax is that the trachea will
eventually shift to the unaffected side.
5. While caring for a patient with a
suspected pneumothorax, you note there
are several areas on the patient’s skin that
appear to be “bulging” out. These “bulging”
areas are located on the patient’s neck,
face, and abdomen. On palpation on these
areas, you note they feel "crunchy". When
charting your findings you would refer to this
finding as?
A. Subcutaneous paresthesia
B. Pigment molle
C. Subcutaneous emphysema
D. Veisalgia
The answer is C. This known as
subcutaneous emphysema or subcutaneous
crepitation.
6. You're providing care to a patient with a
pneumothorax who has a chest tube. On
assessment of the chest tube system, you
note there is no fluctuation of water in the
water seal chamber as the patient inhales
and exhales. You check the system for
kinks and find none. What is your next
nursing action?
A. Keep monitoring the patient because this
is a normal finding.
B. Increase wall suction to the system until
the water fluctuates in the water seal
chamber.
C. Assess patient's lung sounds to assess if
the affected lung has re-expanded.
D. Notify the physician.
The answer is C. It is normal for the water
seal chamber to tidal up and down as the
patient breathes in and out. If there is no
fluctuation of water in the water seal
chamber there may be a kink in the tubing
or the lung has re-expanded. Therefore, it is
important to check the system for kinks and
if there are none then check the patient's
lung sounds to see if lung sounds are
present on the affected side (hence the lung
has re-expanded).
7. A patient is receiving mechanical
ventilation with PEEP. The patient had
developed a tension pneumothorax. Select
ALL the signs and symptoms that can
present with this condition:
A. Hypotension
B. Jugular Venous Distention
C. Bradycardia
D. Tracheal deviation
E. Hyperemia
F. Tachypnea
The answers are A, B, D, and F.
Hypotension, JVD, tracheal deviation, and
tachypnea can all be present in a tension
pneumothorax. The other options are not
usually present.
8. A patient has a chest tube for treatment
of a pneumothorax in the left lung. Which
finding during your assessment requires
immediate nursing intervention?
A. The water seal chamber has intermittent
bubbling.
B. The patient has slight tracheal deviation
to the right side.
C. The water seal chamber fluctuates while
the patient inhales and exhales.
D. The patient complains of tenderness at
the chest tube insertion site.
The answer is B. A patient with a chest tube
is at risk for a tension pneumothorax due to
the risk of pressure building up in the
intrapleural space. Therefore, the nurse
would want to monitor the patient for this
and if tracheal deviation is present this is a
major sign a tension pneumothorax. All the
other options are normal findings. The water
seal chamber will have intermittent (not
excessive) bubbling because of the air that
will be leaving the intrapleural space. The
water seal chamber will flucutate up and
down when the patient breathes in and out,
and it is normal for the patient to have
tenderness at the insertion site of the chest
tube.
9. Which statement is CORRECT about a
tension pneumothorax?
A. This condition happens when an opening
to the intrapleural space creates a two-way
valve which causes pressure to build up in
the space leading to shifting of the
mediastinum.
B. A tension pneumothorax is a medical
emergency and is treated with needle
decompression.
C. Tracheal deviation is an early sign of a
tension pneumothorax
D. An open pneumothorax is the only cause
of a tension pneumothorax.
The answer is B. The only correct statement
about a tension pneumothorax is option B.
Option A is wrong because this condition
happens when an opening to the
intrapleural space creates a ONE-way (not
two-way) valve which causes pressure to
build up in the space leading to shifting of
the mediastinum. Option C is wrong
because tracheal deviation is a LATE (not
early) sign of a tension pneumothorax.
Option D is wrong because not only can an
open pneumothorax cause a tension
pneumothorax but a closed or spontaneous
pneumothroax can as well.
10. A patient receiving treatment for a
pneumothorax calls on the call light to tell
you something is wrong with their chest
tube. When you arrive to the room you note
that the drainage system has fallen on its
side, and there is a large crack in the
system. What is your next PRIORITY?
A. Place the patient in supine position and
clamp the tubing.
B. Notify the physician immediately.
C. Disconnect the drainage system and get
a new one.
D. Disconnect the tubing from the drainage
system and insert the tubing 1 inch into a
bottle of sterile water and obtain a new
system.
The answer is D. A new system needs to be
obtained, however, in order to maintain a
water seal until the new system arrives you
will need to place the tubing 1 inch in sterile
water or sterile saline to regain a water seal.
1. You are providing care to a patient with a
chest tube. On assessment of the drainage
system, you note continuous bubbling in the
water seal chamber and oscillation. Which
of the following is the CORRECT nursing
intervention for this type of finding?
A. Reposition the patient because the tubing
is kinked.
B. Continue to monitor the drainage system.
C. Increase the suction to the drainage
system until the bubbling stops.
D. Check the drainage system for an air
leak.
Continuous bubbling in the water seal
chamber is NOT normal and indicates there
is an air leak. However, oscillation of the
water in the water seal chamber is normal.
2. A patient is receiving positive pressure
mechanical ventilation and has a chest
tube. When assessing the water seal
chamber what do you expect to find?
A. The water in the chamber will increase
during inspiration and decrease during
expiration.
B. There will be continuous bubbling noted
in the chamber.
C. The water in the chamber will decrease
during inspiration and increase during
expiration.
D. The water in the chamber will not move.
When a patient is receiving mechanical
ventilation the water in the water seal
chamber will oscillate oppositely than if the
patient were breathing on their own.
Therefore, the water in the chamber will
decrease during inspiration and increase
during expiration.
3. What type of chest tube system does this
statement describe? This chest drainage
system has no water column to control
suction but uses a suction monitor bellow
that balances the wall suction and you can
adjust water suction pressure using the
rotary suction dial on the side of the system.
It allows for higher suction pressure levels,
has no bubbling sounds, and water does not
evaporate from it as with other systems.
A. Mediastinal chest tube system
B. Dry suction chest tube system
C. Wet suction chest tube system
D. Dry-Wet suction chest tube system
4. The patient in room 2569 calls on the call
light to tell you something is wrong with his
chest tube. When you arrive to the room
you note that the drainage system has fallen
on its side and is leaking drainage onto the
floor from a crack in the system. What is
your next PRIORITY?
A. Place the patient in supine position and
clamp the tubing.
B. Notify the physician immediately.
C. Disconnect the drainage system and get
a new one.
D. Disconnect the tubing from the drainage
system and insert the tubing 1 inch into a
bottle of sterile water and obtain a new
system.
Option D is the best choice. A new system
needs to be obtained, however, in order to
maintain a water seal until the new system
arrives you will need to place the tubing 1
inch in sterile water or sterile saline to
regain a water seal.
5. You're assessing a patient who is post-
opt from a chest tube insertion. On
assessment, you note there is 50 cc of
serosanguinous fluid in the drainage
chamber, fluctuation of water in the water
seal chamber when the patient breathes in
and out, and bubbling in the suction control
chamber. Which of the following is the most
appropriate nursing intervention?
A. Document your findings as normal.
B. Assess for an air leak due to bubbling
noted in the suction chamber.
C. Notify the physician about the drainage.
D. Milk the tubing to ensure patency of the
tubes.
The assessment findings are normal. All the
other options are incorrect.
6. A patient is recovering from a
pneumothorax and has a chest tube
present. Which of the following is an
appropriate finding when assessing the
chest tube drainage system?
A. Intermittent bubbling may be noted in the
water seal chamber.
B. 200 cc of drainage per hour is expected
during recovery of a pneumothorax.
C. The chest tube is positioned at the
patient's chest level to facilitate drainage.
D. All of these options are appropriate
findings.
The answer is A. It is normal to find
intermittent (NOT CONTINUOUS) bubbling
in the water seal chamber if the patient is
recovery from a pneumothorax. Remember
that a pneumothorax is an AIR leak
between the lung and chest wall....therefore
air will escape into the water seal chamber
causing intermittent bubbles.
7. While helping a patient with a chest tube
reposition in the bed, the chest tube
becomes dislodged. What is your immediate
nursing intervention?
A. Stay with the patient and monitor their
vital signs while another nurse notifies the
physician.
B. Place a sterile dressing over the site and
tape it on three sides and notify the
physician.
C. Attempt to re-insert the tube.
D. Keep the site open to air and notify the
physician.
8. A patient is about to have their chest tube
removed by the physician. As the nurse
assisting with the removal, which of the
following actions will you perform? Select-
all-that-apply:
A. Educate the patient how to take a deep
breath out and inhale rapidly while the tube
in being removed.
B. Gather supplies needed which will
include a petroleum gauze dressing per
physician preference.
C. Place the patient in Semi-Fowler's
position.
D. Have the patient take a deep breath,
exhale, and bear down during removal of
the tube.
E. Pre-medicate prior to removal as ordered
by the physician.
F. Place the patient is prone position after
removal.
Option A: is wrong because this is not how
the Valsalva Maneuver is performed (the
correct way is detailed in option D). Option
F: is wrong as well because this position
would not faciltate breathing...Fowler's
position is best after removal.
9. A patient with a chest tube has no
fluctuation of water in the water seal
chamber. What could be the cause of this?
A. This is an expected finding.
B. The lung may have re-expanded or there
is a kink in the system.
C. The system is broken and needs to be
replaced.
D. There is an air leak in the tubing.
1. Question
A 23-year-old male client who has had a
full-thickness burn is being discharged from
the hospital. Which information is most
important for the nurse to provide prior to
discharge?
A. How to maintain home smoke detectors
B. Joining a community reintegration
program
C. Learning to perform dressing changes
D. Options available for scar removal
Correct
Correct Answer: C. Learning to perform
dressing changes
Teaching the patient and his family to
perform dressing changes is critical for the
goal of progression towards independence.
Proper management of burn injury through
proper dressing changes helps prevent
wound deterioration. Encouragement of the
patient and his family members in
participating in dressing changes and
wound care helps prepare for the patient’s
eventual discharge and home care needs.
All other choices (below) are important
during the rehabilitation stage but dressing
changes is a priority.
Option A: Teach on the importance of
installing and maintaining smoke detectors
on every level of the home and changing
batteries periodically to help prevent fires.
Option B: Surviving a burn injury has a
tremendous psychological impact on the
patient and family. The nurse plays a key
role in helping the patient adapt. Providing
referrals to social services and counseling
helps the patient during his rehabilitation
phase.
Option D: Discussion about burn
reconstruction treatment after the scars
have healed or matured is usually
discussed after the first few years after
injury. This option is often used to “improve
both the function and the cosmetic
appearance of burn scars”.
2. Question
A client who is admitted after a thermal burn
injury has the following vital signs: blood
pressure, 70/40; heart rate, 140 beats/min;
respiratory rate, 25/min. He is pale in color
and it is difficult to find pedal pulses. Which
action will the nurse take first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler
device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
Correct
Correct Answer: A. Start intravenous fluids.
Hypovolemic shock is a common cause of
death in the emergent phase of clients with
serious injuries. Administration of fluids can
treat this problem. For burns classified as
severe (> 20% TBSA), fluid resuscitation
should be initiated to maintain urine output
> 0.5 mL/kg/hour.
Option C: Following a severe burn injury,
significant hematologic changes occur that
are reflected in complete blood count (CBC)
measurements. A CBC will be taken to
ascertain if a cardiac or bleeding problem is
causing these vital signs. However, these
are not actions that the nurse would take
immediately.
Option B: Checking pulses would indicate
perfusion to the periphery but this is not an
immediate nursing action. Carefully check
pulses in any extremity with circumferential
burns. These burns can act as tourniquets
as burn-associated edema begins, leading
to compartment syndrome.
Option D: In patients with extensive burns, it
is sometimes a challenge to monitor the
ECG, because the lack of natural skin and
application of protective ointments prevent
the adherence of the ECG discs.
3. Question
A 40-year-old male client who was burned
was admitted under your care. Assessment
reveals he has crackles, respiratory rate of
40/min, and is coughing up blood-tinged
sputum. What action will the nurse take
first?
A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position
Correct
Correct 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 an upright position can
relieve lung congestion immediately before
other measures can be carried out.
Option A: Digoxin may be given later to
increase cardiac contractility to prevent
backup of fluid into the lungs. However,
digoxin has the potential to cause
bradyarrhythmias.
Option B: Chest physiotherapy will not get
rid of the fluid and is not a priority among
the choices. Chest physiotherapy is only
applicable during the post-burn
management of the patient.
Option C: Monitoring urine output is
important. However, it is not an immediate
intervention. Use the patient’s urine output
and physiologic response to determine if the
volume is adequate for resuscitation.
4. Question
How will the nurse position a client with a
burn wound to the posterior neck to prevent
contractures?
A. Have the client turn the head from side
to side.
B. Keep the client in a supine position
without the use of pillows.
C. Keep the client in a semi-Fowler's
position with her or his arms elevated.
D. Place a towel roll under the client's neck
or shoulder.
Incorrect
Correct Answer: A. Have the client turn the
head from side to side.
Deformities and contractures can often be
prevented by proper positioning.
Maintaining proper body alignment when
the patient is in bed is vital. 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. This movement is what would
prevent contractures from occurring.
Option B: The client should not only be in a
supine position but there should be a
movement to avoid contractures. Splinting
and proper positioning will also help achieve
the prevention of contractures. As a matter
of importance, movement should be
incorporated into the patient’s daily routine
from their inception to the hospital.
Option C: The burns are in the client’s
posterior neck. Performing active or passive
range of motion (ROM) exercises,
depending on the patient’s level of
consciousness is crucial in the prevention of
these complications.
Option D: Placing a towel roll under the
neck might not help prevent contractures.
Immobilization is only allowed when a part
of the body has just been grafted. Even
then, the area must be kept in an
antideformity position.
5. Question
On assessment, the nurse notes that the
client has burns inside the mouth and is
wheezing. Several hours later, the wheezing
is no longer heard. What is the nurse’s next
action?
A. Documenting the findings
B. Loosening any dressings on the chest
C. Raising the head of the bed
D. Preparing for intubation
Correct
Correct Answer: D. Preparing for intubation
Clients with severe inhalation injuries may
sustain such progressive obstruction that
they may lose the 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.
Option A: Documentation of findings should
be done after the interventions. There may
be only a small window of opportunity to
easily place an ET tube because edema
from burn shock may obstruct the airway.
Option B: Loosening any dressings on the
chest should be done right after the
assessment of wheezes. If there is edema
or evidence of burn in the upper airways,
assessment for whether an endotracheal
(ET) tube is needed to maintain the airway
should be done immediately.
Option C: The head of the bed should be
flat to prepare for intubation. Emergency
airway intubation should be done
immediately after assessment to avoid
complete obstruction of the airway due to
edema.
6. Question
Ten hours after the client with 50% burns is
admitted, her blood glucose level is 142
mg/dL. What is the nurse’s best action?
A. Documents the finding
B. Obtains a family history of diabetes
C. Repeats the glucose measurement
D. Stop IV fluids containing dextrose
Correct
Correct Answer: A. Documents the finding
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.
Option B: 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
secondary assessment shouldn’t begin until
the primary assessment is complete;
resuscitative efforts are underway; and
lines, tubes, and catheters are placed.
Option C: The glucose level is not high
enough to warrant retesting. A variety of
laboratory tests will be needed within the
first 24 hours of a patient’s admission (some
during the initial resuscitative period and
others after the patient is stabilized).
Option D: The cause of her elevated blood
glucose is not the IV fluid. Rapid and
aggressive fluid resuscitation is needed to
replace intravascular volume and maintain
end-organ perfusion.
7. Question
The client has a large burned area on the
right arm. The burned area appears pink,
has blisters, and is very painful. How will the
nurse categorize this injury?
 A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full-thickness deep
Incorrect
Correct Answer: C. Partial-thickness deep
Deep partial-thickness burns are pink or red
in color, swollen, painful, with blisters that
may ooze a clear fluid. Deep partial-
thickness (second-degree) involves the
deeper dermis. Healing occurs in 3 to 8
weeks with scarring present.
Option A: Third-degree involves the full
thickness of skin and subcutaneous
structures. It appears white or black/brown.
With pressure, no blanching occurs. The
burn is leathery and dry. There is minimal to
no pain because of decreased sensation.
Option B: The characteristics of the wound
meet the criteria for a superficial partial-
thickness injury: color that is red; without
blisters and pain present. Superficial (first-
degree) involves the epidermis of the skin
only. It appears pink to red, there are no
blisters, and it is dry. It is moderately
painful. Superficial burns heal without
scarring within 5 to 10 days.
Option D: Blisters are not seen with full-
thickness burns and are rarely seen with
deep partial-thickness burns. Full-thickness
burns heal by contracture and take greater
than 8 weeks. Full-thickness burns require
skin grafting.
8. Question
The client has burns on both legs. These
areas appear white and leather-like. No
blisters or bleeding are present, and there is
just a “small amount of pain.” How will the
nurse categorize this injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial
Correct
Correct 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. The burn is leathery and dry.
There is minimal to no pain because of
decreased sensation. Full-thickness burns
heal by contracture and take greater than 8
weeks. Full-thickness burns require skin
grafting.
Option B: Superficial partial-thickness
(second-degree) involves the superficial
dermis. It appears red with blisters and is
wet. The erythema blanches with pressure.
The pain associated with superficial partial-
thickness is severe. Healing typically occurs
within 3 weeks with minimal scarring.
Option C: Deep partial-thickness (second-
degree) involves the deeper dermis. It
appears yellow or white, is dry, and does
not blanch with pressure. There is minimal
pain due to a decreased sensation. Healing
occurs in 3 to 8 weeks with scarring
present.
Option D: Superficial (first-degree) involves
the epidermis of the skin only. It appears
pink to red, there are no blisters, and it is
dry. It is moderately painful. Superficial
burns heal without scarring within 5 to 10
days.
9. Question
The client has experienced an electrical
injury of the lower extremities. Which are
the priority assessment data to obtain from
this client?
A. Current range of motion in all extremities
B. Heart rate and rhythm
 C. Respiratory rate and pulse oximetry
reading
D. Orientation to time, place, and person
Correct
Correct Answer: B. Heart rate and rhythm.
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. It is also
important to obtain the patient’s cardiac
history, including any history of prior
arrhythmias.
Option A: Range of motion is also 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.
Option C: The airway is not at any particular
risk with this injury. Therefore, respiratory
rate and pulse oximetry are not priority
assessments. Any patient that was in
contact with a high voltage source should
have continuous cardiac monitoring during
evaluation.
Option D: These patients are specifically at
risk for cardiac damage if the path of the
current traversed the heart. One may also
consider CT imaging of the head if the
patient has altered mental status or
associated head trauma from a fall or being
thrown in a blast.
10. Question
A 35-year-old male client was admitted due
to severe burns around his right hip. Which
position is most important to use to maintain
the maximum function of this joint?
A. Hip maintained in 30-degree flexion
B. Hip at zero flexion with leg flat
C. Knee flexed at 30-degree angle
D. Leg abducted with a foam wedge
Correct
Correct Answer: B. Hip at zero flexion with
leg flat
The 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.
Option A: Anti-contracture positioning and
splinting must start from day one and may
continue for many months post-injury. Legs
should be positioned in a neutral position
ensuring that the patient is not externally
rotating at the hips.
Option C: Patients rest in a position of
comfort; this is generally a position of flexion
and also the position of contracture. Without
ongoing advice and help with positioning,
the patient will continue to take the position
of contracture and can quickly lose ROM in
multiple joints. Once contracture starts to
develop it can be a constant battle to
achieve full movement, so preventative
measures to minimize contracture
development are necessary.
Option D: Splinting helps maintain anti-
contracture positioning particularly for those
patients experiencing a great deal of pain,
difficulty with compliance, or with burns in
an area where positioning alone is
insufficient. If the injured site is over joint
surfaces, special precautions should be
taken to identify all possible joint
contractures.
11. Question
The client who is burned is drooling and
having difficulty swallowing. Which action
will the nurse take first?

A. Assesses level of consciousness and
pupillary reactions
B. Ascertains the time food or liquid was
last consumed
C. Auscultates breath sounds over the
trachea and mainstem bronchi
D. Measures abdominal girth and
auscultates bowel sounds
Correct
Correct 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.
Option A: Knowing the level of
consciousness is important to assess
oxygenation to the brain. In most cases,
neurologic status won’t be altered in the
early stages of burn injury. Use the Glasgow
Coma Scale to trend the patient’s
neurologic status throughout the
resuscitation.
Option B: 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 air exchange is the most
important intervention at this time.
Option D: Measuring abdominal girth is not
relevant in this situation. If there is edema or
evidence of burn in the upper airways,
assess whether an endotracheal (ET) tube
is needed to maintain the airway.
12. Question
A 22-year-old female client with a full-
thickness burn is being discharged to home
after a month in the hospital. Her wounds
are minimally opened and she will be
receiving home care. Which nursing
diagnosis has the highest priority?
A. Acute Pain
B. Deficient Diversional Activity
C. Impaired Adjustment
D. Imbalanced Nutrition: Less than Body
Requirements
Incorrect
Correct 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 her
pre burn 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. This stage starts with the
closure of the burn and ends when the
patient has reached the optimal level of
functioning. The focus is on helping the
patient return to a normal injury-free life.
Helping the patient adjust to the changes
the injury has imposed is also a priority.
Option B: Diversional activity for pain is
applicable during the intermediate phase of
the burn injury. Provide diversional activities
appropriate for age and condition. This
helps lessen concentration on pain
experience and refocus attention.
Option D: Imbalanced nutrition is more
appropriate during the emergent and
intermediate phases of the burn injury.
Appropriate guides to proper caloric intake
include 25 kcal/kg body weight, plus 40 kcal
per percentage of TBSA burn in the adult.
As the burn wound heals, the percentage of
burned areas is reevaluated to calculate
prescribed dietary formulas, and appropriate
adjustments are made.
13. Question
The client with a new burn injury asks the
nurse why he is receiving intravenous
cimetidine (Tagamet). What is the nurse’s
best response?
A. "Tagamet will stimulate intestinal
movement."
B. "Tagamet can help prevent hypovolemic
shock."
C. "This will help prevent stomach ulcers."
D. "This drug will help prevent kidney
damage."
Correct
Correct 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.
Option A: Gastrointestinal stimulants are
drugs that increase motility of the
gastrointestinal smooth muscle, without
acting as a purgative. These drugs have
different mechanisms of action but they all
work to move the contents of the
gastrointestinal tract faster.
Option B: Patients with burns of more than
20% – 25% of their body surface should be
managed with aggressive IV fluid
resuscitation to prevent “burn shock.” Four
mL lactated ringers solution × percentage
total body surface area (%TBSA) burned ×
patient’s weight in kilograms = total amount
of fluid given in the first 24 hours.
Option D: Cimetidine does not prevent
kidney damage. Acute renal failure is one of
the major complications of burns and it is
accompanied by a high mortality rate. Most
renal failures occur either immediately after
the injury or at a later period when sepsis
develops.
14. Question
A 12-year-old male with facial burns asks
the nurse if he will ever look the same.
Which response is best for the nurse to
provide?
A. "With reconstructive surgery, you can
look the same."
B. "We can remove the scars with the use
of a pressure dressing."
C. "You will not look exactly the same."
D. "You shouldn't start worrying about your
appearance right now."
Incorrect
Correct 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. Denial may be prolonged
and be an adaptive mechanism because the
patient is not ready to cope with personal
problems.
Option A: Be realistic and positive during
treatments, in health teaching, and in setting
goals within limitations. This enhances trust
and rapport between patient and nurse.
Option B: Pressure dressings prevent
further scarring. They cannot remove scars.
The client and family should be taught the
expected cosmetic outcomes. Provide hope
within the parameters of the individual
situation; do not give false reassurance.
This promotes a positive attitude and
provides opportunities to set goals and plan
for the future based on reality.
Option D: Acknowledge and accept the
expression of feelings of frustration,
dependency, anger, grief, and hostility. Note
withdrawn behavior and use of denial.
Acceptance of these feelings as a normal
response to what has occurred facilitates
resolution. It is not helpful or possible to
push the patient before he is ready to deal
with the situation.
15. Question
The client with open burn wounds begins to
have diarrhea. The client is found to have a
below-normal temperature, with a white
blood cell count of 4000/mm3. Which is the
nurse’s best action?
A. Continuing to monitor the client
B. Increasing the temperature in the room
C. Increasing the rate of the intravenous
fluids
D. Preparing to do a workup for sepsis
Correct
Correct 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.
Option A: Continuing just to monitor the
situation can lead to septic shock. Indicators
of sepsis (often occurs with full-thickness
burn) requiring prompt evaluation and
intervention. Changes in sensorium, bowel
habits, and the respiratory rate usually
precede fever and alteration of laboratory
studies.
Option B: 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.
Option C: Increasing the rate of intravenous
fluids may be done to replace fluid losses
with diarrhea, but is not the priority action.
Fluid resuscitation replaces lost fluids and
electrolytes and helps prevent complications
(shock, acute tubular necrosis).
Replacement formulas vary but are based
on the extent of injury, amount of urinary
output, and weight.
16. Question
The family of a client who has been burned
asks at what point the client will no longer
be at greater risk for infection. What is the
nurse’s best response?
A. "As soon as he finishes his antibiotic
prescription."
B. "As soon as his albumin level returns to
normal."
C. "When fluid remobilization has started."
D. "When the burn wounds are closed."
Correct
Correct 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.
Option A: Even after the course of treatment
of antibiotics, the patient is still at risk for
infection if the wounds remain open.
Examine wounds daily, note and document
changes in appearance, odor, or quantity of
drainage.
Option B: Albumin levels are monitored if
there is significant edema. Implement
appropriate isolation techniques as
indicated. Depending on the type or extent
of wounds and the choice of wound
treatment (open versus closed), isolation
may range from a simple wound and/or skin
to complete or reverse to reduce the risk of
cross-contamination and exposure to
multiple bacterial flora.
Option C: Fluid resuscitation replaces lost
fluids and electrolytes and helps prevent
complications (shock, acute tubular
necrosis). Once initial fluid resuscitation has
been accomplished, a steady rate of fluid
administration is preferred to boluses, which
may increase interstitial fluid shifts and
cardiopulmonary congestion.
17. Question
The nurse is conducting a home safety
class. It is most important for the nurse to
include which information in the teaching
plan?
A. Have chimneys swept every 2 years.
B. Keep a smoke detector in each
bedroom.
C. Use space heaters instead of gas
heaters.
D. Use carbon monoxide detectors only in
the garage.
Incorrect
Correct 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. Test smoke
alarms every month. If they’re not working,
change the batteries.
Option A: If there is a fireplace, make sure
the chimney is checked and cleaned by a
professional once a year. Use a metal or
glass screen that is large enough to prevent
escaping embers. Make sure home heating
sources are clean and in working order.
Many home fires are started by poorly
maintained furnaces or stoves, cracked or
rusted furnace parts, or chimneys with
creosote buildup.
Option C: Space heaters can be a cause of
fire if clothing, bedding, and other
flammable objects are nearby. Make sure to
always keep anything that gives off heat at
least 3 feet away from flammable materials
or items. Heating equipment, like space
heaters, are involved in 1 of every 6 home
fires. Furthermore, 1 in every 5 home fire
deaths and half of all fires caused by home
heating occur between December and
February.
Option D: Carbon monoxide detectors
should also be placed inside the house, not
only in the garage. A person can be
poisoned by a small amount of CO over a
longer period of time or by a large amount
of CO over a shorter amount of time.
18. Question
The nurse provides wound care for a client
48 hours after a burn injury. To achieve the
desired outcome of the procedure, which
nursing action will be carried out first?
A. Applies silver sulfadiazine (Silvadene)
ointment
B. Covers the area with an elastic wrap
C. Places a synthetic dressing over the
area
D. Removes loose nonviable tissue
Correct
Correct Answer: D. Removes loose
nonviable tissue
The first step in this process is removing
exudates and necrotic tissue. Burn patients
are at high risk for infection, especially drug-
resistant infection, which often results in
significantly longer hospital stays, delayed
wound healing, higher costs, and higher
mortality
Option A: Since the adoption of topical
antibiotics, such as mafenide in the 1960s
and silver sulfadiazine in the 1970s, and of
early excision and grafting in the 1970s and
thereafter, systemic infections and mortality
have consistently decreased. However,
Gram-positive and Gram-negative bacterial
infections still remain one of the most
common causes of mortality following burn
injury.
Option B: While many factors must be
considered in dressing selection, the goals
in selecting the most appropriate dressing
should include providing protection from
contamination (bacterial or otherwise) and
from physical damage, allowing gas
exchange and moisture retention, and
providing comfort to enhance functional
recovery.
Option C: The selection of an appropriate
dressing depends on several factors,
including depth of burn, condition of the
wound bed, wound location, desired
moisture retention and drainage, required
frequency of dressing changes, and cost.
19. Question
The nurse should teach the community that
a minor burn injury could be caused by what
common occurrence?
A. Chimney sweeping every year
B. Cooking with a microwave oven
C. Use of sunscreen agents
D. Use of space heaters
Incorrect
Correct 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. Make sure to always
keep anything that gives off heat at least 3
feet away from flammable materials or
items.
Option A: Chimneys should be swept each
year to prevent creosote build-up and
resultant fire. If there is a fireplace, make
sure the chimney is checked and cleaned
by a professional once a year. Use a metal
or glass screen that is large enough to
prevent escaping embers.
Option B: Burn injuries do not commonly
occur from microwave cooking, but rather
when taking food from it. Thermal burns are
skin injuries caused by excessive heat,
typically from contact with hot surfaces, hot
liquids, steam, or flame. Most burns are
minor and patients can be treated as
outpatients or at local hospitals.
Option C: Lastly, sunscreen agents are
recommended to prevent sunburn. A broad-
spectrum sunscreen with an SPF of at least
30 should be applied 30 minutes before sun
exposure and every 90 minutes after that.
20. Question
The nurse uses topical gentamicin sulfate
(Garamycin) on a client’s burn injury. Which
laboratory value will the nurse monitor?
A. Creatinine
B. Red blood cells
C. Sodium
D. Magnesium level
Correct
Correct 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. In burn
patients, the systemic absorption of topical
gentamicin may be enhanced, and one
should be watchful for the potential
repercussions.
Option B: Topical gentamicin will not affect
the red blood cell count. The gentamicin is
prone to accumulate in the renal proximal
tubular cells and can cause damage.
Hence, mild proteinuria and reduction of the
glomerular filtration rate are potential
consequences of gentamicin use, achieving
14% of gentamicin users in a review.
Option C: Topical gentamicin will not affect
sodium. In cases of renal impairment,
dosing adjustment should be made based
on the glomerular filtration rate (GFR); for a
high-dose, extended interval dosing
approach, the dose can be preserved, but
the interval between doses should increase
in line with GFR decrease.
Option D: Topical gentamicin will not affect
the magnesium level. Renal function should
be evaluated twice-weekly in patients
without previous renal disease through
serum creatinine and blood urea nitrogen.
Periodic microscopic urinalysis is also vital
to detect proteinuria and casts, which may
indicate kidney injury.
1. Question
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.
Correct
Correct 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. Handwashing with
soap and water is the best way to get rid of
germs in most situations. Emphasize and
model good handwashing techniques for all
individuals coming in contact with the
patient.
Option A: Tissue destruction and altered
defense mechanisms increase the risk of
developing tetanus or gas gangrene,
especially in deep burns such as those
caused by electricity.
Option B: Examine wounds daily, note and
document changes in appearance, odor, or
quantity of drainage. Indicators of sepsis
(often occurs with full-thickness burn)
requiring prompt evaluation and
intervention.
Option C: Although all the interventions
listed can help reduce the risk of infection,
hand washing is the most effective
technique for preventing infection
transmission. Airway obstruction and/or
respiratory distress can occur very quickly
or may be delayed, e.g., up to 48 hr after a
burn.
2. Question
Three days after a burn injury, the client
develops a temperature of 100° F, a 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
Correct
Correct Answer: D. Wound infection
Color change, purulent, foul-smelling
drainage, increased white blood cell count,
and fever could all indicate infection.
Indicators of sepsis (often occurs with full-
thickness burn) requiring prompt evaluation
and intervention. Changes in sensorium,
bowel habits, and the respiratory rate
usually precede fever and alteration of
laboratory studies.
Option A: These symptoms will not be seen
in the acute phase of the injury. Assess and
document size, color, depth of wound,
noting necrotic tissue and condition of the
surrounding skin.
Option B: Autodigestion of collagen will not
increase the body temperature or cause
foul-smelling wound discharge. Monitor vital
signs for fever, increased respiratory rate
and depth in association with changes in
sensorium, presence of diarrhea, decreased
platelet count, and hyperglycemia with
glycosuria.
Option C: Granulation of tissue will not
increase the body temperature or cause
foul-smelling wound discharge. Examine
wounds daily, note and document changes
in appearance, odor, or quantity of
drainage.
3. Question
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
Correct
Correct 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.
Option A: Do not give the patient laxative.
The emergent phase starts with the onset of
burn injury and lasts until the completion of
fluid resuscitation or a period of about the
first 24 hours. During the emergent phase,
the priority of patient care involves
maintaining an adequate airway and
treating the patient for burn shock.
Option C: Increased capillary permeability,
protein shifts, inflammatory process, and
evaporative losses greatly affect circulating
volume and urinary output, especially during
the initial 24–72 hr after burn injury. Fluid
replacement formulas partly depend on
admission weight and subsequent changes.
Option D: Maintain proper body alignment
with supports or splints, especially for burns
over joints. This promotes functional
positioning of extremities and prevents
contractures, which are more likely over
joints.
4. Question
What intervention will the nurse implement
to reduce a client’s pain after 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
Correct
Correct Answer: A. Administering morphine
4 mg intravenously.
Drug therapy for pain management requires
opioid and nonopioid analgesics. The
burned patient may require around-the-
clock medication and dose titration. IV
method is often used initially to maximize
drug effect.
Option B: The IV route is used because of
problems with absorption from the muscle
and stomach. Concerns of patient addiction
or doubts regarding the degree of pain
experienced are not valid during the
emergent/acute phase of care, but narcotics
should be decreased as soon as feasible
and alternative methods for pain relief
initiated.
Option C: For the client to avoid shivering,
the room must be kept warm and heat
should be applied. Maintain comfortable
environmental temperature, provide heat
lamps, heat-retaining body coverings.
Temperature regulation may be lost with
major burns. External heat sources may be
necessary to prevent chilling.
Option D: Tactile stimulation can be used
for pain management. Provide basic comfort
measures: massage of uninjured areas,
frequent position changes. This promotes
relaxation and reduces muscle tension and
general fatigue.
5. Question
What statement indicates the client needs
further education regarding 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."
Incorrect
Correct 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. Graft survival depends on the
diffusion of nutrients and oxygen from the
wound bed known as imbibition.
Inosculation then follows when the blood
vessels of the graft and from the wound bed
grow together to make end-to-end contact.
Lastly, neovascularization occurs when new
blood vessels grow from the wound bed into
the graft.
Option B: The donor sites will be painful
after the surgery. Silicone gel sheets, along
with pressure dressings, have shown a
dramatic decrease in pain, pruritis, and scar
thickness six months after burn injury.
Option C: There can be scarring in the area
where the skin is removed for grafting. Burn
scars are a common occurrence after skin
grafting and can cause anxiety, depression,
pain, itching, altered pigmentation,
temperature intolerance, and decreased
range of motion secondary to scar
contracture. Scar formation is propagated
by deficiencies in the biosynthetic and
tissue degradation pathway during wound
healing.
Option D: The client is still at risk for
infection. Early failure of graft survival is
attributable to seroma and hematoma
formation, which lifts the graft off the wound
bed, preventing imbibition. Other factors
that lead to graft failure include shearing
forces, edematous tissue, and infected
tissue.
6. Question
When providing care for a client with an
acute burn injury, which nursing intervention
is most important to prevent infection by
auto contamination?
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
Incorrect
Correct 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.
Use gowns, gloves, masks, and strict
aseptic techniques during direct wound care
and provide sterile or freshly laundered bed
linens or gowns.
Option A: Although all techniques listed can
help reduce the risk of infection, only
changing gloves between carrying out
wound care on different parts of the client’s
body can prevent auto contamination.
Depending on the type or extent of wounds
and the choice of wound treatment (open
versus closed), isolation may range from a
simple wound and/or skin to complete or
reverse to reduce the risk of cross-
contamination and exposure to multiple
bacterial flora.
Option C: Prevent skin-to-skin surface
contact (wrap each burned finger or toe
separately; do not allow burned ear to touch
scalp). This identifies the presence of
healing (granulation tissue) and provides for
early detection of burn-wound infection.
Infection in a partial-thickness burn may
cause conversion of burn to full-thickness
injury.
Option D: Emphasize and model good
handwashing techniques for all individuals
coming in contact with the patient. This
prevents cross-contamination and reduces
the risk of acquired infection.
7. Question
Which assessment finding assists the nurse
in confirming inhalation injury?
A. Brassy cough
B. Decreased blood pressure
C. Nausea
D. Headache
Correct
Correct Answer: A. Brassy cough
Brassy cough and wheezing are some signs
seen with inhalation injury. Damage to
airway tissue causes increased mucus
production, edema, denudation of
epithelium, and mucosal ulceration and
hemorrhage. Obstruction of airflow is often
the effect caused by tissue edema
narrowing the passageways and
mucus/blood/fluid impeding airflow.
Option B: Patients with carbon monoxide
poisoning may exhibit hypotension. As
carboxyhemoglobin (COHgb) levels rise, the
cerebral blood vessels dilate, and both
coronary blood flow and capillary density
increase. Cardiac effects, especially
ventricular arrhythmias occur. Ventricular
arrhythmias are implicated as the cause of
death most often in CO poisoning.
Option C: Most commonly, patients with
carbon monoxide poisoning will present with
headache (more than 90%), dizziness,
weakness, and nausea. Patients may be
tachycardic and tachypneic.
Option D: Patients may have systemic
symptoms like a headache, delirium,
hallucinations, and may even be comatose.
Many different etiologies may cause
changes in mental status including hypoxia,
hypercarbia, or asphyxiant exposure
(carbon monoxide, hydrogen cyanide). But
headaches can also be seen with carbon
monoxide poisoning.
8. Question
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
Incorrect
Correct 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. This phase occurs on days 1-3 and
requires an accurate fluid resuscitation and
thorough evaluation for other injuries and
comorbid conditions.
Option A: Hematocrit can indirectly reflect
the resuscitation effect in the burn shock
stage. Whether hematocrit level can be
lowered to 0.45-0.50 during the first 24
hours after burn may be an important index
for evaluation of fluid resuscitation effect in
the early shock stage after severe burn.
Option B: The average daily heart rate was
elevated in burn patients up to two years
post-burn. Heart rate was elevated despite
any afforded resuscitative efforts. While
research data are up to two years post-
injury, the heart rate of severely burned
children was still 120% of predicted
compared to normal values for children.
Option C: Swelling tends to occur soon after
injury and generally decreases after 48–72
hours, although this timescale can vary. The
extent and location of the swelling will
depend on how the burn was caused and
the location and depth of the burn injury. It
is very important that the swelling is
reduced as soon as possible.
9. Question
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
Correct
Correct Answer: C. Performing his own
morning care
Indicators that the client with a burn injury
has a positive perception of his appearance
include 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.
Option A: Encourage the patient and SO to
view wounds and assist with care as
appropriate. This promotes acceptance of
the reality of injury and of change in body
and image of self as different.
Option B: Discussing future reconstruction
would not indicate a positive perception of
appearance. Assist the patient to identify
the extent of actual change in appearance
and body function. This helps begin the
process of looking to the future and how life
will be different.
Option D: Wearing the dressing will assist in
decreasing complications, but will not
increase self-perception. However, give
positive reinforcement of progress and
encourage endeavors toward attainment of
rehabilitation goals. Words of
encouragement can support the
development of positive coping behaviors.
10. Question
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."
Correct
Correct 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.
Option B: Assist the patient and the family
to express their feelings of grief and guilt.
The patient and the family may initially be
most concerned about the patient’s death
and/or feel guilty, believing that in some way
they could have prevented the incident.
Option C: Acknowledge and accept the
expression of feelings of frustration,
dependency, anger, grief, and hostility. Note
withdrawn behavior and use of denial.
Acceptance of these feelings as a normal
response to what has occurred facilitates
resolution. It is not helpful or possible to
push the patient before ready to deal with
the situation.
Option D: Assist the patient to identify the
extent of actual change in appearance and
body function. 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. Question
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
Correct
Correct 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.
Urine output of 0.5 mL/kg or about 30 – 50
mL/hr in adults and 0.5-1.0 mL/kg/hr in
children less than 30kg is a good target for
adequate fluid resuscitation.
Option A: Blood pressure is usually low.
During this inflammatory response, there is
a fluid loss that can cause a sharp and
potentially deadly drop in blood pressure
known as shock.
Option B: A foul-smelling discharge does
not occur during the emergent phase. Third-
degree involves the full thickness of skin
and subcutaneous structures. It appears
white or black/brown. With pressure, no
blanching occurs. The burn is leathery and
dry.
Option C: Pain does not occur with deep
full-thickness burns. There is minimal to no
pain because of decreased sensation. Full-
thickness burns heal by contracture and
take greater than 8 weeks. Full-thickness
burns require skin grafting.
12. Question
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
Correct
Correct 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.
Option B: Disturbed body image can
develop. Assist the patient to identify the
extent of actual change in appearance and
body function. This helps begin the process
of looking to the future and how life will be
different.
Option C: Disuse syndrome can develop.
Risk for disuse syndrome may be related to
the physiological changes brought about by
physical inactivity. These changes may
include a decrease in muscle strength,
limited joint movement, and loss of bone
density. However, this is not a priority
diagnosis at this time.
Option D: Chemical burns do not cause
inhalation injury and a disrupted breathing
pattern. The most common findings
represent structural changes to the tissue
directly affected, for example, the eye, oral
mucosa, skin, esophagus, and lower
intestinal system, especially the stomach
and pylorus, respiratory system, among
others.
13. Question
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)
Correct
Correct 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 of experiencing severe cardiac
dysrhythmias and death.
Option A: Acid-base studies were carried
out on 76 consecutive burn patients
admitted within 36 hours of injury.
Admission blood pH and base excess (BE)
values all decreased in a linear relationship
to the extent of the burn. Blood Pco-2
changes were unrelated to the extent of the
burn. Significant acidosis developed within 2
hours of burn injury.
Option B: The hematocrit (Hct) is the
percentage of the volume of the whole
blood that is made up of red blood cells. In
burns, the patient has lost a lot of fluid from
leaky blood vessels. There are more red
cells than fluid so the hematocrit is high.
Option D: Serum sodium is abnormal, but
not to the same degree of severity, and
would be expected in the emergent phase
after a burn injury. Severe cutaneous
injuries such as burn injuries and blast
injuries result in the loss of both water and
sodium. For burn patients, hypernatremia
that occurs within a few days of injury may
be associated with an increased risk of
death.
14. Question
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
Incorrect
Correct 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.
Ascertain food likes and dislikes. Encourage
SO to bring food from home, as appropriate.
This provides the patient or SO a sense of
control; enhances participation in care and
may improve intake.
Option B: Parenteral nutrition may be given
as a last resort because it is invasive and
can lead to infectious and metabolic
complications. Total parenteral nutrition
(TPN) maintains nutritional intake and
meets metabolic needs in presence of
severe complications or sustained
esophageal or gastric injuries that do not
permit enteral feedings.
Option C: Clients who can eat solid foods
should ingest as many calories as possible.
Appropriate guides to proper caloric intake
include 25 kcal/kg body weight, plus 40 kcal
per percentage of TBSA burn in the adult.
As the burn wound heals, the percentage of
burned areas is reevaluated to calculate
prescribed dietary formulas, and appropriate
adjustments are made.
Option D: The nurse needs to work with a
nutritionist to provide a high-calorie, high-
protein diet to help with wound healing.
Refer to a dietitian or nutrition support team.
This may be useful in establishing individual
nutritional needs (based on weight and body
surface area of injury) and identifying
appropriate routes.
15. Question
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."
Correct
Correct 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.

Option A: The final stage in caring for a
patient with a burn injury is the rehabilitative
stage. This stage starts with the closure of
the burn and ends when the patient has
reached the optimal level of functioning. The
focus is on helping the patient return to a
normal injury-free life. Helping the patient
adjust to the changes the injury has
imposed is also a priority.
Option B: Early compliance is essential to
ensure the best possible long-term outcome
and also to ease pain and assist with
exercise regimes. Patients need to adhere
to a positioning regime in the early stages of
healing and this takes teamwork and
dedication.
Option D: Rehabilitation of burns patients is
a continuum of active therapy starting from
admission. There should be no delineation
between an ‘acute phase’ and a
‘rehabilitation phase’ as this idea can
promote the inequality of secondary
disjointed scar management and/or
functional rehabilitation team.
16. Question
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."
Incorrect
Correct 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. Hypertrophic
burn scars pose a challenge for burn
survivors and providers. In many cases,
they can severely limit a burn survivor’s
level of function, including work and
recreational activities.
Option B: 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. A widespread
modality of prevention and treatment of
hypertrophic scarring is the utilization of
pressure garment therapy (PGT).
Option C: The pressure garment will not
alter the risk of infection. At present, PGT is
the standard first-line therapy for
hypertrophic burn scars in many centers
due to its non-invasive characteristics and
presumed desirable treatment effects with
few associated complications.
Option D: Scars will still be present. This
treatment modality continues to be a
clinically accepted practice. It is the most
common therapy used for the treatment and
prevention of abnormal scars after burn
injury particularly in North America, Europe,
and Scandinavia where it is considered
routine practice and regarded as the
preferred conservative management with
reported thinning and better pliability
ranging from 60% to 85%.
17. Question
The client with a dressing covering the neck
is experiencing some respiratory difficulty.
What is the nurse’s initial action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only
action.
Incorrect
Correct 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.
Generally, it is recommended that pressure
should be maintained between 20 and 30
mm Hg, which is above capillary pressure
but less than what would diminish peripheral
blood circulation.
Option A: It is unnecessary to administer
oxygen. Wearing pressure garments is
uncomfortable and challenging; problems
with movement, appearance, fit, comfort,
swelling of extremities, rashes, and
blistering are common; consequently, low
compliance with PGT is to be expected.
Option C: The nurse may intervene first.
However, monitoring of pressure exerted by
pressure garments is currently difficult and
time-consuming, and not routinely done and
currently, the optimal pressure magnitude
for PGT remains unsolved.
Option D: The nurse may loosen the
dressing to help the client breathe. Recent
evidence suggests that pressure garment
therapy is effective for the prevention and/or
treatment of abnormal scarring after burn
injury but that the clinical benefit is restricted
to those patients with moderate or severe
scarring.
18. Question
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
Correct
Correct Answer: D. Increased serum
creatinine level
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.
Characteristically, gentamicin reaches high
concentrations in the renal cortex and the
inner ear.
Option A: Gentamicin does not stimulate
pain in the wound. The gentamicin is prone
to accumulate in the renal proximal tubular
cells and can cause damage. Hence, mild
proteinuria and reduction of the glomerular
filtration rate are potential consequences of
gentamicin use, achieving 14% of
gentamicin users in a review.
Option B: The small, pale pink bumps in the
wound bed are areas of re-epithelialization
and not an adverse reaction. Renal function
should be evaluated twice-weekly in
patients without previous renal disease
through serum creatinine and blood urea
nitrogen. Periodic microscopic urinalysis is
also vital to detect proteinuria and casts,
which may indicate kidney injury.
Option C: The possible hypersensitivity
manifestations of gentamicin are urticaria,
eosinophilia, delayed-type hypersensitivity
reaction (Stevens-Johnson syndrome and
toxic epidermal necrolysis), angioedema,
and anaphylactic shock. The clinical
manifestations should guide the treatment
strategy.
19. Question
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.
Correct
Correct 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.
Use gowns, gloves, masks, and strict
aseptic techniques during direct wound care
and provide sterile or freshly laundered bed
linens or gowns.
Option B: Although all techniques listed can
help reduce the risk of infection, only
changing gloves between carrying out
wound care on different parts of the client’s
body can prevent autocontamination.
Depending on the type or extent of wounds
and the choice of wound treatment (open
versus closed), isolation may range from a
simple wound and/or skin to complete or
reverse to reduce the risk of cross-
contamination and exposure to multiple
bacterial flora.
Option C: Prevent skin-to-skin surface
contact (wrap each burned finger or toe
separately; do not allow burned ear to touch
scalp). This identifies the presence of
healing (granulation tissue) and provides for
early detection of burn-wound infection.
Infection in a partial-thickness burn may
cause conversion of burn to full-thickness
injury.
Option D: Emphasize and model good
handwashing techniques for all individuals
coming in contact with the patient. This
prevents cross-contamination and reduces
the risk of acquired infection.
20. Question
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
Incorrect
Correct 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 failure and pulmonary
edema during fluid resuscitation.
Option A: Asthma is a chronic inflammatory
disease of the airways, characterized by
recurrent episodes of airflow obstruction
resulting from edema, bronchospasm, and
increased mucus production. Commonly
associated with seasonal allergies (allergic
rhinitis) and eczema (atopic dermatitis),
these three conditions form what is known
as the atopic triad.
Option B: The incubation period of an acute
hepatitis B virus infection is approximately
12 weeks, with a majority of patients
experiencing mild illness and less than 1%
experiencing fulminant hepatic failure. After
acute infection resolves, the majority of
adult patients and a small percentage of
infected infants develop antibodies against
the hepatitis B surface antigen and end up
recovering fully.
Option D: Nephrolithiasis, or kidney stones,
is the most common condition affecting the
urinary system, affecting about 12% of the
world population, with a yearly incidence of
600,000 in America. It is the result of a
crystal or crystalline concretion traveling
from the kidney through the genitourinary
system.
1. Question
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.
Administer Tramadol (Tramal) 50 mg IV.
Debride the wound of eschar using gauze
sponges.
Obtain a sample for wound culture.
Apply silver nitrate ointment.
Cover the wound using a sterile gauze
dressing.
Incorrect
The correct order is shown above
Rationale:
Pain medication is administered prior to the
dressing change since the type of burn will
be painful during the procedure. Opioids
may be required initially to control pain, but
once first aid measures have been effective
non-steroidal anti-inflammatory drugs such
as ibuprofen or co-dydramol taken orally will
suffice.
Then the wound is debrided before getting
the sample for culture to prevent other
bacteria that can contaminate the actual
wound. It is important to realize that a new
burn is essentially sterile, and every attempt
should be made to keep it so. The burn
wound should be thoroughly cleaned with
soap and water or mild antibacterial wash
such as dilute chlorhexidine.
Obtain a sample for wound culture. Burn
wound infections are one of the most
important and potentially serious
complications that occur in the acute period
following injury
An antibacterial cream such as silver nitrate
is applied to the area to attain the maximum
effect of the medication. Flamazine is silver
sulfadiazine cream and is applied topically
on the burn wound. It is effective against
gram-negative bacteria including
Pseudomonas.
Lastly, cover the wound using a sterile
dressing. Depending on how healing is
progressing, dressing changes thereafter
should be every three to five days. If the
Jelonet dressing has become adherent, it
should be left in place to avoid damage to
the delicate healing epithelium. If Flamazine
is used it should be changed on alternate
days.
2. Question
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.
Incorrect
Correct 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. The FDA has issued a black box
warning regarding the use of amitriptyline in
adolescents and young adults (ages less
than 24 years). It can increase the risk of
suicidal ideation and behavior.
Option A: Omeprazole is indicated for the
short-term treatment of peptic ulcer disease
in adults where most patients heal within
four weeks. Patients with duodenal ulcer
disease and H. pylori infection disease that
is active for up to one year may benefit from
combination therapy that includes
omeprazole with clarithromycin, amoxicillin,
and metronidazole.
Option B: Silver sulfadiazine is a medication
used in the prevention, management, and
treatment of burn wound infections. It is a
heavy metal topical agent with antibacterial
properties. Typically burn dressings consist
of topical silver sulfadiazine combined with
fine mesh gauze and are usable in both the
inpatient and outpatient settings.
Option C: All health facilities practice
double-checking of medications prior to
administration, Of all the medications given,
Amitriptyline is the most important to
double-check with another licensed nurse.
3. Question
The nurse is administering fluids
intravenously as ordered to a client who
acquired a full-thickness burn injury on the
abdomen. To determine the sufficiency of
fluid resuscitation, the nurse would monitor
which of the following would provide the
most reliable parameter for determining
adequacy?
A. Level of consciousness
B. Peripheral pulses
C. Urine output
D. Vital signs
Incorrect
Correct Answer: C. Urine output
Of all the options, urine output is the most
reliable indicator for determining the
adequacy of fluid resuscitation. Urine output
of 0.5 mL/kg or about 30 – 50 mL/hr in
adults and 0.5-1.0 mL/kg/hr in children less
than 30kg is a good target for adequate fluid
resuscitation.
Option A: Heart rate, mental status, and
capillary refill may be affected by the
underlying disease process and are less
reliable markers. The actual endpoint of
fluid therapy in shock is to optimize tissue
perfusion. However, this parameter is not
measured directly. Surrogate endpoints
include clinical indicators of end-organ
perfusion and measurements of preload.
Option B: Because of compensatory
vasoconstriction, mean arterial pressure
(MAP) is only a rough guideline; organ
hypoperfusion may be present despite
apparently normal values. Because urine
output does not provide a minute-to-minute
indication, measures of preload may be
helpful in guiding fluid resuscitation for
critically ill patients.
Option D: Patient’s vital signs, mental
status, capillary refill, and urine output must
be monitored and fluid rates adjusted
accordingly. Recent literature has raised
concerns about complications from over-
resuscitation described as “fluid creep.”
Again, adequate fluid resuscitation is the
goal.
4. Question
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.
Correct
Correct 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. Although a patient may
be capable of spontaneous breathing in the
early hours after a burn, compromise of the
airway can still develop. This may be due to
external pressure on the airway, with edema
developing in the head and neck region, or
in the upper airway due to inhalation of hot
gases, including steam or aspiration of hot
liquids.
Option A: Split-thickness grafts can cover
the extensive defects created after scar
release. These grafts will need meticulous
attention to achieve complete and early
wound closure, but thereafter prolonged
splinting will be important to maintain
release and prevent contracture.
Option B: In the superficial burn, wound
dressings suffice. These can be biological
or synthetic. Some medicated elements can
prevent secondary infection. Superficial
facial wounds can also be treated exposed,
with or without the application of topical
ointments.
Option D: Opioids may be given to this
patient. These burns need to be shaved to
preserve residual elements capable of
regeneration. Burns of the face and neck
rarely fall into aesthetic units, and
professional judgment must determine how
the excision should be performed. Grafting
should be in aesthetic units if at all possible,
and sheet grafts should be used on the
face.
5. Question
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
Correct
Correct Answer: D. Intravenous
For clients with major burns, the
intravascular route is the preferred choice of
medication administration. Patient-
controlled analgesia (PCA) with IV opioids is
a safe and efficient method of achieving
flexible analgesia in burn-injured patients.
Studies comparing PCA with other routes of
administration have shown mixed results as
to benefit and patient satisfaction.
Option A: Oral NSAIDs and acetaminophen
are mild analgesics that exhibit a ceiling
effect in their dose-response relationship.
Such limitations render these agents
unsuitable for the treatment of typical,
severe burn pain. Oral NSAIDS and
acetaminophen are of benefit in treating
minor burns, usually in the outpatient
setting.
Option B: In intramuscular drug
administration, the absorption of the drug is
determined by the bulk of the muscle and its
vascularity. The onset and duration of the
action of the drug is not adjustable. In case
of inadvertent scenarios such as
anaphylaxis, burns, or neurovascular
injuries, intravenous (IV) assess needs to
be secured
Option C: Subcutaneous injections are
another form of the parenteral route of
medication and are administered to the
layer of skin referred to as cutis, just below
the dermis and epidermis layers.
Subcutaneous tissue has few blood vessels;
therefore, the medications injected undergo
absorption at a slow, sustained rate.
6. Question
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
Incorrect
Correct Answer: B. Confusion
Signs and symptoms of carbon monoxide
levels between 21-40% (moderate
poisoning) include hypotension,
tachycardia, headache, drowsiness,
confusion, nausea, and vomiting. Mental
status changes such as altered level of
consciousness, disorientation, and memory
loss may occur.
Option A: Carbon monoxide levels of 41%
to 60% result in seizures. As
carboxyhemoglobin (COHgb) levels rise, the
cerebral blood vessels dilate, and both
coronary blood flow and capillary density
increase. If exposure continues, central
respiratory depression develops which may
result from cerebral hypoxia.
Option C: Carbon monoxide levels of 11%
to 20% result in flushing. The classic
symptoms of cherry red nail beds and
mucous membranes are not “classic” and
are usually post-mortem findings. Patients
may also develop ataxia, apraxia,
incontinence, and cortical blindness.
Option D: Cardiac effects, especially
ventricular arrhythmias occur. Ventricular
arrhythmias are implicated as the cause of
death most often in CO poisoning. There is
evidence that myocardial impairment begins
at the relatively low level of COHgb of 20%.
7. Question
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 (TBSA) that has been burned?
A. 36%
B. 54%
C. 45%
D. 27%
Correct
Correct Answer: A. 36%
The Rule of Nines, also known as the
Wallace Rule of Nines, is a tool used by
trauma and emergency medicine providers
to assess the total body surface area
(TBSA) involved in burn patients. Based on
the rule of nines, the posterior trunk equals
18%, right arm equals 9%, and the left
posterior leg equals 9%. Therefore, a total
of 36%.
Option B: The Rule of Nines estimation of
body surface area burned is based on
assigning percentages to different body
areas. The entire head is estimated as 9%
(4.5% for anterior and posterior). The entire
trunk is estimated at 36% and can be further
broken down into 18% for anterior
components and 18% for the back.
Option C: The anterior aspect of the trunk
can further be divided into chest (9%) and
abdomen (9%). The upper extremities total
18% and thus 9% for each upper extremity.
Each upper extremity can further be divided
into anterior (4.5%) and posterior (4.5%).
Option D: The lower extremities are
estimated at 36%, 18% for each lower
extremity. Again this can be further divided
into 9% for the anterior and 9% for the
posterior aspect. The groin is estimated at
1%.
8. Question
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.
Correct
Correct 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%. Non-rebreathing
masks have a bag attached to the mask
known as a reservoir bag, which inhalation
draws from to fill the mask through a one-
way valve and features ports at each side
for exhalation, resulting in an ability to
provide the patient with 100% oxygen at a
higher LPM flow rate.
Options A and C: The nasal cannula is a
thin tube, often affixed behind the ears and
used to deliver oxygen directly to the
nostrils from a source connected with
tubing. This is the most common method of
delivery for home use and provides flow
rates of 2 to 6 liters per minute (LPM)
comfortably, allowing the delivery of oxygen
while maintaining the patient’s ability to
utilize his or her mouth to talk, eat, etc.
Option D: An air-entrainment (also known
as venturi) mask can provide a pre-set
oxygen to the patient using jet mixing. As
the percent of inspired oxygen increases
using such a mask, the air-to-oxygen ratio
decreases, causing the maximum
concentration of oxygen provided by an air-
entrainment mask to be around 40%.
9. Question
The nurse is handling a client who
sustained an 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
Incorrect
Correct 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. A fasciotomy is an emergency
procedure used to treat acute compartment
syndrome. Acute compartment syndrome
often follows high energy trauma, fractures,
circumferential burns, crush injuries, or even
a tight plaster cast.
Option A: Loss of sensation can signal
compartment syndrome. Classical features
of compartment syndrome are those of
ischemia, pain out of proportion to the
injury, paraesthesia, pallor, paralysis, and
pain on passive movement, especially
stretch of the concerned compartment.
Option B: Pallor is associated with
compartment syndrome. Fasciotomy wound
management begins with an inspection at
48 hours. If the compartments are soft, this
closure is achievable by primary wound
closure, secondary wound healing, or as
needed in approximately 50% of wounds
split-thickness skin grafting.
Option C: Distal circulation should be
checked to prevent ischemia. Two-point
discrimination can be useful for determining
nerve ischemia. These signs and symptoms
can be challenging to assess depending on
the conscious level, sensory state, and
ability to communicate.
10. Question
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 activities 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.
Correct
Correct 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. Clinically, skin grafts are
secured into place and often bolstered until
postoperative day 5 to 7 to allow the skin
graft to go through the above steps,
ensuring the best skin graft take.
Option B: Do not place the affected leg in a
dependent position. Any buildup of fluid
between the split-thickness skin graft and
wound bed will jeopardize skin graft take,
including seroma, hematoma, and infection.
Shear or traction injury also disrupts skin
graft healing.
Option C: Dangling of legs puts the affected
site into a dependent position, which can
cause a build-up of fluid that jeopardizes the
skin graft. The graft can have incomplete
(less than 100%) take or complete nontake.
Option D: Split-thickness skin grafts typically
become adherent to the recipient wound
bed 5 to 7 days following skin graft
placement. The dressings placed
intraoperatively are kept in place until 5 to 7
days postoperatively to minimize shear and
traction to the healing skin graft.
11. Question
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 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 that has been crying since recent
visitors left.
Incorrect
Correct Answer: B. A 40-year-old with
partial-thickness leg burns which has a
temperature of 101.9°F and blood pressure
of 89/48 mm Hg.
The client’s vital signs indicate that life-
threatening complications of sepsis may be
developing. Burn wound infections are one
of the most important and potentially serious
complications that occur in the acute period
following injury. If the patient’s host
defenses and therapeutic measures
(including excision of necrotic tissue and
wound closure) are inadequate or delayed,
microbial invasion of viable tissue occurs,
which is the hallmark of an invasive burn
wound infection.
Option A: Classically, hyperkalemia has
been regarded as a complication in patients
with electrical burns. The etiology of
hyperkalemia includes metabolic acidosis,
destruction of red blood cells,
rhabdomyolysis, and the development of
renal failure.
Option C: Oral NSAIDs and acetaminophen
are of benefit in treating minor burns,
usually in the outpatient setting. For
hospitalized burn patients, opioids are the
cornerstone of pharmacologic pain control.
Patient-controlled analgesia (PCA) with IV
opioids is a safe and efficient method of
achieving flexible analgesia in burn-injured
patients.
Option D: Symptoms of depression and
anxiety are common and start to appear in
the acute phase of recovery. Acute stress
disorder (occurs in the first month) and post-
traumatic stress disorder (occurs after one
month) are more common after burns than
other forms of injury.
12. Question
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
Correct
Correct 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. The acute phase of
burns is defined as a period extending from
the onset of burns with shock to the time
taken for wound epithelialization which
normally takes about 12 to 14 days if the
management of burns is adequate. The first
48 is the period of shock.
Option C: Pulse rate is higher than normal.
If resuscitation is carried out urgently the
circulatory shock is not only prevented,
none of the complications of shock are
allowed to manifest.
Option D: Initially, blood is shunted away
from the kidneys, resulting in low urine
output. The greatest amount of fluid loss in
burn patients is in the first 24 h after injury.
For the first 8-12 hours, there is a general
shift of fluids from intravascular to interstitial
fluid compartments. This means that any
fluid given during this time will rapidly leak
out from the intravascular compartment.
13. Question
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.
Incorrect
Correct Answer: D. Wearing gloves and a
gown only when giving direct care to the
client.
Thorough hand washing is performed
before and after each contact with the burn-
injured client. During the delivery of
healthcare, avoid unnecessary touching of
surfaces in close proximity to the patient to
prevent both contaminations of clean hands
from environmental surfaces and
transmission of pathogens from
contaminated hands to surfaces.
Option A: The physical action of washing
and rinsing hands under such
circumstances is recommended because
alcohols, chlorhexidine, iodophors, and
other antiseptic agents have poor activity
against spores.
Option B: Protective garbs such as masks,
gloves, caps, shoe covers, gowns, and a
plastic apron need to be worn when having
direct contact with the client. Remove
gloves after contact with a patient and/or the
surrounding environment (including medical
equipment) using proper technique to
prevent hand contamination.
Option C: Sterile sheets and linen are used
due to the high risk of infection. Soiled
textiles, including bedding, towels, and
patient or resident clothing may be
contaminated with pathogenic
microorganisms. However, the risk of
disease transmission is negligible if they are
handled, transported, and laundered in a
safe manner.
14. Question
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.
Correct
Correct 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 increased amount
of lactated Ringer’s solution administered
hourly. Patients with burns of more than
20% – 25% of their body surface should be
managed with aggressive IV fluid
resuscitation to prevent “burn shock.” Urine
output of 0.5 mL/kg or about 30 – 50 mL/hr
in adults and 0.5-1.0 mL/kg/hr in children
less than 30kg is a good target for adequate
fluid resuscitation.
Option B: Blood transfusion is not used for
fluid resuscitation therapy unless there is an
indication of a low hemoglobin level. This
response, along with decreased cardiac
output and increased vascular resistance,
can lead to marked hypovolemia and
hypoperfusion called “burn shock.” This can
be managed with aggressive fluid
resuscitation and close monitoring for
adequate, but not excessive, IV fluids.
Option C: Diuretic works by removing
circulating volume, thereby further
compromising the inadequate tissue
perfusion. The patient’s vital signs, mental
status, capillary refill, and urine output must
be monitored and fluid rates adjusted
accordingly. Again, adequate fluid
resuscitation is the goal.
Option D: Dextrose in water will only
maintain fluid balance since it is an isotonic
solution, therefore will not be helpful in this
situation. Four mL lactated ringers solution
× percentage total body surface area
(%TBSA) burned × patient’s weight in
kilograms = total amount of fluid given in the
first 24 hours.
15. Question
Nurse Kelsey is a nurse manager assigned
to the burn unit. Which client is best to
assign 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.
Incorrect
Correct 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. There are
several options for burn dressings. Some
are impregnated with antimicrobials (eg,
silver). Most are a form of gauze, but there
are biosynthetic dressings with some of the
characteristics of skin that adhere to the
wound and can be left in place for extended
periods of time.
Option B: Admission assessment requires
expertise in caring for burn patients. The
needs of the client must be competently met
with the knowledge, skills and abilities of the
staff to meet these needs. In other words,
the nurse who delegates aspects of care to
other members of the nursing team must
balance the needs of the client with the
abilities of those to which the nurse is
delegating tasks and aspects of care.
Option C: Splinting requires expertise in
caring for burn patients. The staff members’
levels of education, knowledge, past
experiences, skills, abilities, and
competencies are also evaluated and
matched with the needs of all of the patients
in the group of patients that will be cared
for.
Option D: Discharge teaching requires
expertise in caring for burn patients.
Validated and documented competencies
must also be considered prior to assignment
of patient care. No aspect of care can be
assigned or delegated to another nursing
staff member unless this staff member has
documented evidence that they are deemed
competent by a registered nurse to do so.
16. Question
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
Incorrect
Correct 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 heals within a week, without
scarring. Superficial burns (first degree)
involve only the epidermis and are warm,
painful, red, soft, and blanch when touched.
Usually, there is no blistering. A typical
example is a sunburn.
Option B: Pale pink or mottled appearance
with associated swelling and small blisters.
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. Full-thickness burns (third
degree) extend through both the epidermis
and dermis and into the subcutaneous fat or
deeper. These burns have little or no pain,
can be white, brown, or charred, and feel
firm and leathery to palpation with no
blanching.
17. Question
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
Incorrect
Correct Answer: B. Homograft
Homograft is a tissue graft from a donor of
the same species as the recipient. Skin from
organ donors can be used as a temporary
covering. It is temporary because this skin
will eventually be rejected. This is known as
a homograft. Homografts may be required
initially if the injured area is too large to be
covered by the patient’s own skin.
Option A: A skin graft, also known as an
autograft, involves taking skin from an
unburned part of the patient’s body and
placing it on the wound after the burn has
been removed.
Option C: Pigskin grafts are termed
xenografts, or heterografts because they
are transplanted from an organism of one
species to that of a different species. Both
allografts and xenografts are biologic
dressings only, are ultimately rejected by
the patient’s immune system, and need to
be removed prior to definitive wound
treatment or skin grafting.
Option D: Xenograft is a graft of tissue
taken from a donor of one species and
grafted into a recipient of another species.
While xenografts are rejected before
undergoing revascularization, allografts
initially undergo revascularization but are
typically rejected after approximately 10
days because of the strong antigenicity of
the skin.
18. Question
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.
Correct
Correct Answer: B. Avoid smoking.
Smoking can decrease the blood supply to
the newly graft recipient bed interface, and
the chance of graft failure increases. The
combined effect of nicotine and carbon
monoxide is deadly to the healing process.
This can result in partial or complete loss of
healing of the wound, skin graft, flap, or any
combination of these. This can compromise
the cosmetic results of the surgery.
Option A: Static or primary splints are used
in the acute phase for skin graft protection
after surgery or anti contracture positioning.
These splints are applied to adjacent intact
skin.
Option C: Healed burns or skin grafts may
be extremely sensitive to sunlight and may
sunburn more severely even after short
periods of time in the sun compared to
before the injury. Sun sensitivity after a burn
injury may last for a year or more.
Option D: At least 3 weeks after surgery,
avoid exercise that stretches the skin graft,
unless the doctor gives other instructions. If
the graft was placed on the legs, arms,
hands, or feet, the patient may need
physiotherapy to prevent scar tissue from
limiting movement.
19. Question
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."
Correct
Correct Answer: C. “It is performed at the
bedside and without anesthesia”.
An escharotomy is performed at the bedside
and without anesthesia since nerve endings
have been destroyed by the burn injury. An
escharotomy is an emergency surgical
procedure involving incising through areas
of burnt skin to release the eschar and its
constrictive effects, restore distal circulation,
and allow adequate ventilation.
Option A: A skin graft, also known as an
autograft, involves taking skin from an
unburned part of the patient’s body and
placing it on the wound after the burn has
been removed.
Option B: Escharotomy involves making a
lengthwise incision through the burn eschar
to relieve vasoconstriction. The incisions
should extend from unburnt skin to unburnt
skin ideally, or at least into areas of more
superficial burns, down to subcutaneous fat,
and release any constrictions.
Option D: This is a selective method for
debridement of necrotic tissue using an
exogenous proteolytic enzyme,
collagenase, to debride Clostridium
bacteria. Collagenase digests the collagen
in the necrotic tissue allowing it to detach.
20. Question
Rehabilitation is the final phase of 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.
Correct
Correct Answer: A, C, and E.
The rehabilitation phase starts after wound
closure and ends upon discharge and
beyond. The goals of this phase include
minimizing functional loss, promoting
psychosocial support, promoting wound
healing, and proper nutrition.
Option A: Patients may try to refuse
treatment as they are in pain and may not
fully understand the impact of not
participating in their rehabilitation; they,
therefore, need the support and
encouragement of the burn care
professionals to help them through this
difficult experience with the knowledge of
how different their quality of life can be.
Option B: Inflammatory and vasoactive
mediators such as histamines,
prostaglandins, and cytokines are released
causing a systemic capillary leak,
intravascular fluid loss, and large fluid shifts.
These responses occur mostly over the first
24 hours peaking at around six to eight
hours after injury. This can be managed
with aggressive fluid resuscitation and close
monitoring for adequate, but not excessive,
IV fluids.
Option C: Continuous monitoring and
reassessment of nutritional status with
modifications in nutritional therapy as
indicated can accommodate the unique yet
diverse needs of this population and support
their therapeutic goals for recovery.
Option D: Belong to the main goal during
the resuscitative phase. Patients with burns
of more than 20% – 25% of their body
surface should be managed with aggressive
IV fluid resuscitation to prevent “burn
shock.”
Option E: A comprehensive rehabilitation
program is essential to decrease a patient’s
post-traumatic effects and improve
functional independence. While different
professionals possess expertise in their own
specialties, there are some simple and
effective methods that can be utilized to
help the patient reach their maximum
functional outcome.
1. Question
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
Correct
Correct Answer: D. Full thickness
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). With pressure, no blanching
occurs. The burn is leathery and dry. There
is minimal to no pain because of decreased
sensation. Full-thickness burns heal by
contracture and take greater than 8 weeks.
Full-thickness burns require skin grafting.
Option A: Superficial (first-degree) involves
the epidermis of the skin only. It appears
pink to red, there are no blisters, and it is
dry. It is moderately painful. Superficial
burns heal without scarring within 5 to 10
days.
Option B: Superficial partial-thickness
(second-degree) involves the superficial
dermis. It appears red with blisters and is
wet. The erythema blanches with pressure.
The pain associated with superficial partial-
thickness is severe. Healing typically occurs
within 3 weeks with minimal scarring.
Option C: Deep partial-thickness (second-
degree) involves the deeper dermis. It
appears yellow or white, is dry, and does
not blanch with pressure. There is minimal
pain due to a decreased sensation. Healing
occurs in 3 to 8 weeks with scarring
present.
2. Question
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
Incorrect
Correct 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; pain
present and high). Superficial partial-
thickness (second-degree) involves the
superficial dermis. It appears red with
blisters and is wet. The erythema blanches
with pressure. The pain associated with
superficial partial-thickness is severe.
Healing typically occurs within 3 weeks with
minimal scarring.
Option A: Superficial (first-degree) involves
the epidermis of the skin only. It appears
pink to red, there are no blisters, and it is
dry. It is moderately painful. Superficial
burns heal without scarring within 5 to 10
days.
Option C: Deep partial-thickness (second-
degree) involves the deeper dermis. It
appears yellow or white, is dry, and does
not blanch with pressure. There is minimal
pain due to a decreased sensation. Healing
occurs in 3 to 8 weeks with scarring
present.
Option D: Third-degree involves the full
thickness of skin and subcutaneous
structures. It appears white or black/brown.
With pressure, no blanching occurs. The
burn is leathery and dry. There is minimal to
no pain because of decreased sensation.
Full-thickness burns heal by contracture and
take greater than 8 weeks. Full-thickness
burns require skin grafting.
3. Question
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.
Correct
Correct Answer: C. The danger of an
overdose during fluid remobilization is
reduced.
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.
Option A: 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. Pain that is more
severe and not well controlled may be
manageable with single or continuous
doses of IV, epidural, and intrathecal
formulations. Infusion dosing can vary
significantly between patients and largely
depends on how naive or tolerant they are
to opiates.
Option B: Respiratory depression is among
the more serious adverse reactions with
opiate use that is especially important to
monitor in the postoperative patient
population. Extreme caution is necessary
with severe respiratory depression and
asthma exacerbation cases since morphine
can further decrease the respiratory drive.
Option D: Delayed gastric emptying is not a
side effect of morphine. Among the more
common unwanted effects of morphine use
is constipation. This effect occurs via
stimulation of mu-opioid receptors on the
myenteric plexus, which in turn inhibits
gastric emptying and reduces peristalsis.
4. Question
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
Correct
Correct Answer: D. Vitamin 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.
The loss of healthy skin following a burn
injury can decrease epidermal vitamin D
production. Additionally, low vitamin D
levels have been reported to have
continued for 7 years post-burn in pediatric
outpatients.
Option A: Vitamin A deficiency (VAD) is a
highly prevalent health concern associated
with substantial morbidity and mortality,
mostly affecting young children in
impoverished regions throughout the world.
Insufficient intake of absorption leads to
deficiency and compromise of essential
physiologic processes.
Option B: Vitamin B12 deficiency can lead
to hematologic and neurological symptoms.
Vitamin B12 is stored in excess in the liver,
decreasing the likelihood of deficiency.
However, in cases in which vitamin B12
cannot be absorbed, for example, due to
dietary insufficiency, malabsorption, or lack
of intrinsic factor, hepatic stores are
depleted, and deficiency ensues.
Option C: Vitamin C deficiency, also known
as scurvy, is a disease primarily associated
with socioeconomic status and access to
food. Signs and symptoms are often readily
visible in individuals who develop this
disease. The classic constellation of
corkscrew hairs, perifollicular hemorrhage,
and gingival bleeding is highly suggestive of
vitamin C deficiency.
5. Question
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.
Correct
Correct Answer: C. The burned areas
include the hands and perineum.
Burns of the perineum increase the risk for
sepsis. Burns of the hands require special
attention to ensure the best functional
outcome. Complications are related to the
extension of the burn. Burns to the genitalia
and perineum are severe conditions that all
urologists should be familiar with and know
how to manage. Fluid resuscitation is the
initial step in treating these patients and is
followed by topical dressings in the case of
superficial burns.
Option A: Irrespective of the type of burn
injury, the aged population shows slower
recoveries and suffers more complications.
Age-associated immune dysfunction,
immunosenescence, may predispose the
elderly burn patients to more infections,
slower healing, and/or to other
complications.
Option B: Accordingly, patients with burn
injury cannot be considered recovered when
the wounds have healed; instead, burn
injury leads to long-term profound
alterations that must be addressed to
optimize quality of life.
Option D: Burns to the genitals correspond
to approximately 2% of all burn patients in
North American case series. The majority of
those cases are associated with greater
burned body surface areas, in which direct
fire and scalding are the most frequent
causes. Burn management begins with
opportune diagnosis and entails making the
correct classification, depending on the
depth of the lesion.
6. Question
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 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.”
Correct
Correct Answer: C. “To decrease
hydrochloric acid production in the stomach
and prevent 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.
Cimetidine inhibits the production and
release of hydrochloric acid.
Option A: Adequate fluid therapy is crucial
in maintaining renal function. Monitoring by
urine output or Swan-Ganz catheterization
and thermodilution cardiac output
determination is useful in the circulatory
management of severely burned patients.
Albumin infusion increases plasma volume
by 37% and normalizes elevated basal
levels of aldosterone and plasma renin
activity.
Option B: Other management for severe
burns includes nasogastric tube placement
as most patients will develop ileus. Foley
catheters should be placed to monitor urine
output. Cardiac and pulse oximetry
monitoring are indicated. Pain control is
best managed with IV medication.
Option D: Patients with burns of more than
20% – 25% of their body surface should be
managed with aggressive IV fluid
resuscitation to prevent “burn shock.” A
variety of formulas exist, like Brooke,
Galveston, Rule of Ten, etc.4, but the most
common formula is the Parkland Formula.
This formula estimates the amount of fluid
given in the first 24 hours, starting from the
time of the burn.
7. Question
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
Correct
Correct Answer: C. During fluid
remobilization
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. In an attempt to prevent
hypokalemia it is advised to add ’20-30
mEq/1 of potassium to the hypotonic fluids
in order to compensate for urinary losses
and intracellular shift; it is also mandatory to
correct precipitating factors such as
increased pH, hypomagnesemia, and
several drugs.
Option A: In major burns. intravascular
volume is lost in burned and unburned
tissues: this process is due to an increase in
vascular permeability, increased interstitial
osmotic pressure in burn tissue. and cellular
edema. with the most significant shifts
occurring in the first hours. Hyponatremia is
frequent, and the restoration of sodium
losses in the burn tissue is, therefore,
essential hyperkalemia is also characteristic
of this period because of the massive tissue
necrosis.
Option B: The early post-resuscitation
phase is a period of transition from the
shock phase to the hypermetabolic phase,
and fluid strategies should change radically
with a view to restoring losses due to water
evaporation. The main changes in this
period are hypernatremia, hypocalcemia,
hypokalemia, hypomagnesemia, and
hypophosphatemia.
Option D: The acute phase of burns is
defined as a period extending from the
onset of burns with shock to the time taken
for wound epithelialization which normally
takes about 12 to 14 days if management of
burns is adequate.
8. Question
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
Correct
Correct Answer: C. Cherry red color to the
mucous membranes
The saturation of hemoglobin molecules
with carbon monoxide and the subsequent
vasodilation induces a “cherry red” color of
the mucous membranes in these clients.
Cherry-red skin color associated with
severe carbon monoxide poisoning is seen
in only 2-3% of symptomatic cases. Skin
may develop erythematous lesions and
bulla, especially over bony prominences.
Option A: Carbon monoxide quickly binds
with hemoglobin with an affinity greater than
that of oxygen to form COHb. The resulting
decrease in arterial oxygen content and shift
of the oxyhemoglobin dissociation curve to
the left explains the acute hypoxic
symptoms (primarily neurologic and cardiac)
seen in patients with acute poisoning.
Option B: Patients suffering from smoke
inhalation may have symptoms of burning
sensation in the nose or throat (which is
often caused by an irritant chemical toxin), a
cough with increased sputum production,
stridor, and dyspnea with rhonchi or
wheezing.
Option D: The other manifestations are
associated with inhalation injury, but not
specifically carbon monoxide poisoning.
Physical examination should include looking
for facial burns, such as loss of facial and
intranasal hair as well as carbonaceous
material or soot in the mouth or sputum.
9. Question
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.
Correct
Correct Answer: C. Capillary refill is slow in
the digits and the distal pulse is absent.
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.
Option A: The American Burn Association
recommends burn center referrals for
patients with full-thickness burns. Patients
being transferred to burn centers do not
need extensive debridement or topical
antibiotics before transfer.
Option B: Once established, burn
contractures can be treated with serial
splinting, release of contracting bands with
Z-plasties, incision, and skin grafting or
excision, and resurfacing with skin grafts or
flaps, local rotation flaps, use of tissue
expanders, or with free flap reconstruction.
Option D: After a deep burn injury,
cutaneous nerve regeneration will occur
with the migration of new nerve fibers from
the wound bed or from the collateral
sprouting of nerve fibers from adjacent
uninjured areas. This nerve regeneration
process is imperfect. It was reported that
71% of extensively burned victims suffer
from abnormal sensations and 36% from
chronic pain. Recent studies on rats have
shown that vagus nerve stimulation
improved thermal injury-induced shock
symptoms.
10. Question
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
Correct
Correct Answer: D. Hemoglobin S
electrophoresis
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.
Option A: Burn patients can also have
important reduction in albumin level due to a
higher vascular permeability in the burn
wounds that produces exudation with an
important protein loss through the burn
wound and acute phase response of plasma
protein synthesis in liver that occurs with
even a very small percentage of burn skin
(0.8%) and that produces a decrease to
about 80% of normal albumin and
prealbumin levels.
Option B: Immunochemical studies of the
sera of patients with severe burns led to the
conclusion that as soon as within the first
two days following the trauma, tissue
antigens sharing common components with
those of the burned and normal skin were
detected in the blood. The antigens in
question were not detected in the sera of
healthy subjects and were not identical with
the C-reactive protein. Long-term circulation
of these antigens, i.e. for 2 to 3 months after
burning, was revealed.
Option C: For the detection of prostate
cancer, an elevated serum prostate-specific
antigen is the most common laboratory
abnormality, as the majority of men with
early prostate cancer have no symptoms.
However, prostate-specific antigen,
otherwise known as PSA, is clinically
imprecise as benign and malignant
processes both can elevate the serum
marker.
11. Question
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
Correct
Correct Answer: B. Crystalloids
Although not universally true, most fluid
resuscitation for burn injuries starts with
crystalloid solutions, such as normal saline
and Ringer’s lactate. Burn patients receive a
larger amount of fluids in the first hours than
any other trauma patients. Initial
resuscitation is based on crystalloids
because of the increased capillary
permeability occurring during the first 24 h.
After that time, some colloids, but not all,
are accepted.
Option A: Colloids 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.
Option C: Fresh frozen plasma appears to
be a useful and effective immediate burn
resuscitation fluid but its benefits must be
weighed against its costs, and risks of viral
transmission and acute lung injury.
Option D: The burn client rarely requires
blood during the emergent phase unless the
burn is complicated by another injury that
involves hemorrhage. Ongoing blood loss,
anemia, hypoxia, and cardiac disease are
the most common reasons for blood
transfusion in burn patients. Other important
causes include age, percentage of burn
(TBSA), need for further operation,
presence of acute respiratory distress
syndrome, sepsis, and evidence of cardiac
ischemia.
12. Question
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.
Correct
Correct 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.
Generally, it is recommended that pressure
should be maintained between 20 and 30
mm Hg, which is above capillary pressure
but less than what would diminish peripheral
blood circulation.
Option A: It is unnecessary to administer
oxygen. Wearing pressure garments is
uncomfortable and challenging; problems
with movement, appearance, fit, comfort,
swelling of extremities, rashes, and
blistering are common; consequently, low
compliance with PGT is to be expected.
Option C: The nurse may intervene first.
However, monitoring of pressure exerted by
pressure garments is currently difficult and
time-consuming, and not routinely done and
currently, the optimal pressure magnitude
for PGT remains unsolved.
Option D: The nurse may loosen the
dressing to help the client breathe. Recent
evidence suggests that pressure garment
therapy is effective for the prevention and/or
treatment of abnormal scarring after burn
injury but that the clinical benefit is restricted
to those patients with moderate or severe
scarring.
13. Question
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.
Correct
Correct Answer: B. Notify the emergency
team.
Clients with severe inhalation injuries may
sustain such progressive obstruction that
they may lose the 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.
Option A: Raising the head of the bed would
be not much help because of the obstructed
airway. Airway protection should include
considering early and preemptive intubation
for patients with inhalation injury.
Option C: Dressings may be loosened, but
emergency intubation would still be needed.
Airway edema may occur suddenly as
edema worsens, and often, the upper
airways develop injury and obstruction
earliest, prior to the parenchymal injury.
Option D: This is not a normal finding. There
may be accessory muscle usage,
tachypnea, cyanosis, stridor, and
rhonchi/rales/wheezing. Findings of stridor
or upper airway turbulence/noise are often a
sign of impending airway compromise, and
prompt intubation should be strongly
considered.
14. Question
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.
Correct
Correct Answer: B. Document the finding as
the only action.
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.
Option A: The glucose level is not high
enough to alert the emergency team. A
variety of laboratory tests will be needed
within the first 24 hours of a patient’s
admission (some during the initial
resuscitative period and others after the
patient is stabilized).
Option C: 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
secondary assessment shouldn’t begin until
the primary assessment is complete;
resuscitative efforts are underway; and
lines, tubes, and catheters are placed.
Option D: Infusion of an IV fluid containing
dextrose may further increase the client’s
blood glucose. The ideal burn resuscitation
is the one that effectively restores plasma
volume, with no adverse effects. Isotonic
crystalloids, hypertonic solutions, and
colloids have been used for this purpose,
but every solution has its advantages and
disadvantages. None of them is ideal, and
none is superior to any of the others.
15. Question
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
Correct
Correct Answer: A. Fluid shift
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. After a
burn, fluid shifts from vascular to interstitial
and intracellular spaces because of
increased capillary pressure, increased
capillary and venular permeability,
decreased interstitial hydrostatic pressure,
chemical inflammatory mediators, and
increased interstitial protein retention.
Option B: Intense pain and carbon
monoxide poisoning increase blood
pressure. Superficial dermal burns are
initially the most painful. Even the slightest
change in the air currents moving past the
exposed superficial dermis causes a patient
to experience excruciating pain. Without the
protective covering of the epidermis, nerve
endings are sensitized and exposed to
stimulation.
Option C: Hemorrhage is unusual in a burn
injury. The difference with a burn is the heat
actually stops the blood from flowing. A
small bit of blood may ooze out at first, but it
won’t actually bleed much.
Option D: Most commonly, patients with
carbon monoxide poisoning will present with
headache (more than 90%), dizziness,
weakness, and nausea. Patients may be
tachycardic and tachypneic. They may
exhibit hypotension. Mental status changes
such as confusion, altered level of
consciousness, disorientation, and memory
loss may occur.
16. Question
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.
Correct
Correct Answer: B. Document the finding as
the only action.
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. After the mid and late 1990s, the idea
of staged food intake was advanced: a
small amount of light fluid is started several
hours after burn so as to not only
supplement nutrition but stimulate GI
peristalsis and improve GI blood supply.
Once bowel sound resumes, the amount of
food can be increased.
Option A: Post-burn GI dysfunction is
caused by multiple factors, and therefore
maintaining GI function is a systematic
engineering project. The therapeutic
strategy should not rely on a single
treatment or a single drug.
Option C: It is suggested that small doses of
dopamine should be administered to dilate
the renal and GI vessels, and free oxygen
radical clearing agents to attenuate
ischemia/reperfusion injury in the process of
resuscitation. These comprehensive
resuscitation measures played an important
role in protecting GI function, helping
resume bowel sound earlier and digestive
function.
Option D: In some patients in whom fluid
resuscitation was not implemented
effectively for various reasons, wound
surface infection often caused severe injury
to the GI function, or even toxic paralytic
ileus palsy, greatly increasing toxin
absorption and bacterial superinfection.
17. Question
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
Correct
Correct Answer: A. Increased urine output,
decreased urine specific gravity
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. Injured
capillaries heal approximately 24 to 36
hours after a burn, so intravascular fluid loss
typically ceases at this time, and fluid
begins to shift back into the intravascular
compartment. This stage is called the fluid
remobilization period.
Option B: Edema develops when the rate at
which fluid is filtered out of the capillaries
exceeds the flow in the lymph vessels.
Edema formation often follows a biphasic
pattern. An immediate and rapid increase in
the water content of burned tissue is seen in
the first hour after burn injury.
Option C: Inadequate fluid resuscitation is
the most common cause of diminished
distal pulses in the newly burned patient.
Another potential cause of diminished
pulses is peripheral edema, which develops
in many severe burn patients due to the
large fluid volumes needed for resuscitation.
Option D: Hyponatraemia is frequent, and
the restoration of sodium losses in the burn
tissue is, therefore, essential hyperkalemia
is also characteristic of this period because
of the massive tissue necrosis. Following a
severe burn injury, significant hematologic
changes occur that are reflected in
complete blood count (CBC)
measurements. Over the first week after
injury, HGB and HCT decreased. This
decrease was due to loss of red blood cells.
WBC counts were initially elevated but
decreased over the first 4 days. PLT also
decreased over the first 4 days.
18. Question
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
Correct
Correct Answer: C. Risk for Disuse
Syndrome
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.
Option A: Chemical burns do not cause
inhalation injury and a disrupted breathing
pattern. The most common findings
represent structural changes to the tissue
directly affected, for example, the eye, oral
mucosa, skin, esophagus, and lower
intestinal system, especially the stomach
and pylorus, respiratory system, among
others.
Option B: 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.
Option D: Disturbed body image can
develop. Assist the patient to identify the
extent of actual change in appearance and
body function. This helps begin the process
of looking to the future and how life will be
different.
19. Question
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%
Correct
Correct Answer: B. Serum potassium 7.5
mmol/L (mEq/L)
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 of experiencing severe cardiac
dysrhythmias and death.
Option A: Serum sodium is abnormal, but
not to the same degree of severity, and
would be expected in the emergent phase
after a burn injury. Severe cutaneous
injuries such as burn injuries and blast
injuries result in the loss of both water and
sodium. For burn patients, hypernatremia
that occurs within a few days of injury may
be associated with increased risk of death.
Option C: Acid-base studies were carried
out on 76 consecutive burn patients
admitted within 36 hours of injury.
Admission blood pH and base excess (BE)
values all decreased in a linear relationship
to the extent of the burn. Blood Pco-2
changes were unrelated to the extent of the
burn. Significant acidosis developed within 2
hours of burn injury.
Option D: The hematocrit (Hct) is the
percentage of the volume of the whole
blood that is made up of red blood cells. In
burns, the patient has lost a lot of fluid from
leaky blood vessels. There are more red
cells than fluid so the hematocrit is high.
20. Question
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
Correct
Correct Answer: B. Heart rate and rhythm
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. It is also
important to obtain the patient’s cardiac
history, including any history of prior
arrhythmias.
Option A: The airway is not at any particular
risk with this injury. Any patient that was in
contact with a high voltage source should
have continuous cardiac monitoring during
evaluation.
Option C: These patients are specifically at
risk for cardiac damage if the path of the
current traversed the heart. One may also
consider CT imaging of the head if the
patient has altered mental status or
associated head trauma from a fall or being
thrown in a blast.
Option D: Range of motion is also
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.
1. Question
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?”
Correct
Correct Answer: D. “In what exact place or
space were you when you were burned?”
The risk for inhalation injury is greatest
when flame burns occur indoors in small,
poorly ventilated rooms. The composition of
smoke varies with each fire depending upon
the materials being burned, the amount of
oxygen available to the fire, and the nature
of the fire. It is important to elucidate
whether the exposure was to smoke,
flames, and/or possible chemicals (both
industrial and household). Duration of
exposure, the location of exposure (such as
if it was in an enclosed space), and any loss
of consciousness are all important as well.
Option A: Although smoking increases the
risk for some problems, it does not
predispose the client for an inhalation injury.
History-taking should be complete and
thorough. Burn patients may have extensive
external injuries, but smoke inhalation may
affect those with no outward signs of burns.
Option B: Workup of smoke inhalation injury
may include serial chest radiographs (often
negative early in smoke inhalation injury)
and computed tomography (CT) chest. A
delay in the onset of symptoms is not
uncommon, and clinicians should educate
patients on the possibility of delayed
symptom onset post-exposure. The delayed
symptoms occur in the lower respiratory
airways as it is caused by chemical toxin
exposure, which may bypass the upper
airways.
Option C: Short-term complications are
seen in more severe injuries within 4 to 5
days, and the most common issue is
pneumonia. Acute respiratory distress
syndrome and pulmonary edema are also
seen in the short term.
2. Question
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.
Correct
Correct Answer: C. The client’s oxygen
saturation is 97%.
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.
Option A: A thorough respiratory
assessment consists of inspection,
palpation, percussion, and auscultation in
conjunction with a comprehensive health
history. Use a systematic approach and
compare findings between left and right so
the patient serves as his own control.
Option B: Respirations should be even,
unlabored, and regular at a rate of 12 to 20
breaths per minute. Normally, inspiration is
half as long as expiration, and chest
expansion is symmetrical. If the client
appears anxious or exhibits nasal flaring,
cyanosis of the lips and mouth, intercostal
retraction, or use of accessory muscles of
respiration, he may be in respiratory
distress.
Option D: Normally, the thorax is
symmetrical and the anterior-posterior
diameter is less than the transverse
diameter. (Equal diameters may signal
chronic obstructive pulmonary disease in an
adult.) Note any structural deformity such as
a pigeon chest (pectus carinatum) or funnel
chest (pectus excavatum).
3. Question
The nursing instructor is going over burn
injuries. The instructor tells the students that
the nursing care priorities for a patient with
a burn injury include wound care, nutritional
support, and prevention of complications
such as infection. Based upon these care
priorities, the instructor is most likely
discussing a patient in what phase of burn
care?
A. Emergent Phase
B. Immediate Resuscitative Phase
C. Acute Phase
D. Rehabilitation Phase
Correct
Correct Answer: C. Acute Phase
The acute or intermediate phase of burn
care follows the emergent/resuscitative
phase and begins 48 to 72 hours after the
burn injury. During this phase, attention is
directed toward continued assessment and
maintenance of respiratory and circulatory
status, fluid and electrolyte balance, and
gastrointestinal function. Infection
prevention, burn wound care that includes
wound cleaning, topical antibacterial
therapy, wound dressing, dressing changes,
wound debridement, and wound grafting,
pain management, and nutritional support
are priorities at this stage and are discussed
in detail in the following sections.
Option A: The emergent phase begins with
the onset of burn injury and lasts until the
completion of fluid resuscitation or a period
of about the first 24 hours. During the
emergent phase, the priority of client care
involves maintaining an adequate airway
and treating the client for burn shock.
Option B: Priorities during the immediate
resuscitative phase include first aid,
prevention of shock and respiratory distress,
detection and treatment of concomitant
injuries, and initial wound assessment and
care.
Option D: The priorities during the
rehabilitation phase include prevention of
scars and contractures, rehabilitation,
functional and cosmetic reconstruction, and
psychosocial counseling.
4. Question
The burned client’s family asks 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.”
Correct
Correct Answer: B. “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 great risk for
infection as long as any area of skin is
open.
Option A: Fluid resuscitation replaces lost
fluids and electrolytes and helps prevent
complications (shock, acute tubular
necrosis). Once initial fluid resuscitation has
been accomplished, a steady rate of fluid
administration is preferred to boluses, which
may increase interstitial fluid shifts and
cardiopulmonary congestion.
Option C: The important point to remember
is the fluid amount calculated is just a
guideline. Patient’s vital signs, mental
status, capillary refill, and urine output must
be monitored and fluid rates adjusted
accordingly. Urine output of 0.5 mL/kg or
about 30 – 50 mL/hr in adults and 0.5-1.0
mL/kg/hr in children less than 30kg is a
good target for adequate fluid resuscitation.
Recent literature has raised concerns about
complications from over-resuscitation
described as “fluid creep.” Again, adequate
fluid resuscitation is the goal.
Option D: Severe burn is associated with
significant changes in body weight due to
large resuscitation volumes, fluid shifts, a
hypermetabolic state, prolonged bed rest,
and caloric intake. Weight gain in the
severely burned patient often follows initial
fluid resuscitation, which can increase
weight by up to 10–20 kg.
5. Question
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
Correct
Correct 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 failure and pulmonary
edema during fluid resuscitation. The initial
response to severe burn injury or early
shock state is characterized by a decrease
in cardiac output and metabolic rate. The
reduction in cardiac output is partially due to
hypovolemia and reduced venous return.
Option A: Systemic effects may occur
especially after inhalation injury. Systemic
effects of inhalation injury occur both
indirectly from hypoxia or hypercapnia
resulting from loss of pulmonary function
and systemic effects of pro-inflammatory
cytokines, as well as direct effects from
metabolic poisons such as carbon
monoxide and cyanide.
Option B: A history of hepatitis B does not
affect the fluid resuscitation plan. Fluid
creep in patients recovering from acute
burns still exists, despite the use of a more
treatment conservative approach. Most
severe burn patients develop fluid overload
and body weight increase after acute fluid
resuscitation. How to quickly return patients
to their pre-injury body weight is an
important issue
Option D: Acute renal failure is one of the
major complications of burns and it is
accompanied by a high mortality rate. Most
renal failures occur either immediately after
the injury or at a later period when sepsis
develops.
6. Question
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.
Correct
Correct Answer: C. Auscultate breath
sounds over the trachea and mainstem
bronchi.
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. Close
physical examination of patients with
inhalation injury can reveal signs of smoke
inhalation, including facial burns, perioral
burns, and singed nasal hairs. This warrants
laryngoscopy and evidence of significant
edema, blisters, or ulcerations should lead
to consideration for intubation to stabilize
the airway.
Option A: Neurovascular assessment may
be done after establishing a patent airway.
Inhalation of smoke also leads to the
absorption of many toxins in the blood,
including carbon monoxide and cyanide,
thereby causing the entire body to be
affected, and making inhalational injury a
systemic insult.
Option B: History taking can be done after
the patient has been deemed stable. It is
well known that rapid diagnosis and
treatment are key when it comes to
inhalational burns, as acute complications,
which sometimes go unnoticed, are the
reason behind long-term sequels and the
high mortality rate seen with this type of
injury.
Option D: GI assessment is not a priority.
Edema of the oral mucosa and/or the
trachea can develop within 0.5 hours of the
time of injury and can progress to mucosal
necrosis within 12-24 hours. Supraglottic
injury, swelling, and resulting obstruction of
the airway occur more commonly in children
due to the smaller size of the trachea, and
relatively large epiglottis.
7. Question
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
Incorrect
Correct Answer: A. Handwashing on
entering the client’s room
Cross-contamination occurs when
microorganisms from another person or the
environment are transferred to the client.
Handwashing with soap and water is the
best way to get rid of germs in most
situations. Emphasize and model good
handwashing techniques for all individuals
coming in contact with the patient.
Option B: Although all the interventions
listed above can help reduce the risk of
infection, only handwashing can prevent
cross-contamination. Airway obstruction
and/or respiratory distress can occur very
quickly or may be delayed, e.g., up to 48 hr
after a burn.
Option C: Tissue destruction and altered
defense mechanisms increase the risk of
developing tetanus or gas gangrene,
especially in deep burns such as those
caused by electricity.
Option D: Serious complications often can
be avoided by following strict aseptic
techniques. Use of a mask, hat, gown, and
sterile gloves, and drapes during placement
of central venous catheters (CVCs) should
be strictly implemented.
8. Question
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.
Incorrect
Correct Answer: C. The “bands” outnumber
the “segs.”
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.
Option A: The normal WBC count is 4,500
to 11,000/mm3. Burn injury causes systemic
inflammatory response. The magnitude of
the changes is roughly a function of burn
size that is manifested by increased body
temperature, increased WBC count, and
increased metabolic rate, which makes
diagnosis of infection in the burned patient
more difficult.
Option B: Peripheral blood lymphocytes
represent the most important line of host
defense against pathogenic microorganisms
in humans. Researchers found a reduction
in the number of lymphocytes as well as
WBC, which may contribute to the
impairment of general mechanisms for
immune regulation during burn shock and
transition of blood to the level of self-
regulation.
Option D: The normal monocyte count
ranges from 100-700 per mm3 (2–8%).
Severe burn and sepsis profoundly inhibit
the functions of DC, monocyte, and
macrophage. These phagocytes are the first
cellular responders to severe burn injury
after acute disruption of the skin barrier.
9. Question
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.
Correct
Correct Answer: C. Have the client turn the
head from side to side 90 degrees every
hour while awake.
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. Deformities and
contractures can often be prevented by
proper positioning. Maintaining proper body
alignment when the patient is in bed is vital.
This movement is what would prevent
contractures from occurring.
Option A: Placing a towel roll under the
neck might not help prevent contractures.
Immobilization is only allowed when a part
of the body has just been grafted. Even
then, the area must be kept in an
antideformity position.
Option B: The client should not only be in a
supine position but there should be a
movement to avoid contractures. Splinting
and proper positioning will also help achieve
the prevention of contractures. As a matter
of importance, movement should be
incorporated into the patient’s daily routine
from their inception to the hospital.
Option D: The burns are in the client’s
posterior neck. Performing active or passive
range of motion (ROM) exercises,
depending on the patient’s level of
consciousness is crucial in the prevention of
these complications.
10. Question
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
Incorrect
Correct Answer: D. 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 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.
Option A: Anti-contracture positioning and
splinting must start from day one and may
continue for many months post-injury. Legs
should be positioned in a neutral position
ensuring that the patient is not externally
rotating at the hips.
Option B: When burns occur to the flexor
aspect of a joint or limb the risk of
contracture is greater. This is due to the
position of comfort being a flexed position;
also the flexor muscles are generally
stronger than the extensors so should a
burn occur to the extensor aspect, patients
can use the strength of the flexors to stretch
the particular area.
Option C: Patients rest in a position of
comfort; this is generally a position of flexion
and also the position of contracture. Without
ongoing advice and help with positioning,
the patient will continue to take the position
of contracture and can quickly lose ROM in
multiple joints. Once contracture starts to
develop it can be a constant battle to
achieve full movement, so preventative
measures to minimize contracture
development are necessary.
11. Question
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
Correct
Correct 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.
Option A: Gentamicin does not stimulate
pain in the wound. The gentamicin is prone
to accumulate in the renal proximal tubular
cells and can cause damage. Hence, mild
proteinuria and reduction of the glomerular
filtration rate are potential consequences of
gentamicin use, achieving 14% of
gentamicin users in a review.
Option B: The small, pale pink bumps in the
wound bed are areas of re-epithelialization
and not an adverse reaction. Renal function
should be evaluated twice-weekly in
patients without previous renal disease
through serum creatinine and blood urea
nitrogen. Periodic microscopic urinalysis is
also vital to detect proteinuria and casts,
which may indicate kidney injury.
Option C: The possible hypersensitivity
manifestations of gentamicin are urticaria,
eosinophilia, delayed-type hypersensitivity
reaction (Stevens-Johnson syndrome and
toxic epidermal necrolysis), angioedema,
and anaphylactic shock. The clinical
manifestations should guide the treatment
strategy.
12. Question
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.
Correct
Correct Answer: D. Notify the burn
emergency team.
These findings are associated with systemic
gram-negative infection and sepsis. This is
a medical emergency and requires prompt
attention. Invasive infection of burn wounds
is a surgical emergency because of the high
concentrations of bacteria (>105 CFU) in
the wound and surrounding area, together
with new areas of necrosis in unburned
tissues.
Option A: Invasive infection is now the chief
reason for death and morbidity after burn
injury, with it being responsible for 51% of
the deaths. The importance of prevention,
surveillance, and sampling for infections in
this immunocompromised group has been
well established; however, there is a dearth
of standard-of-care guidelines and novel
approaches.
Option B: Urgent resuscitation measures
are required, along with broad-spectrum
antimicrobial agents, antifungals, and
surgical debridement of the affected area.
Specimens of this tissue must undergo
histopathologic and microbiologic analysis
to assist in the identification of the causative
organism(s).
Option C: Assessment of the airway and
oxygen saturation would not help in
diagnosing a burn infection. Burn wound
colonization may be diagnosed when
bacteria are present at low concentrations
(<105 colony-forming units [CFU]) on the
wound’s surface. This situation often is
accompanied by signs of sepsis and
changes in the burn wound such as black,
blue, or brown discoloration of the eschar.
13. Question
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.
Correct
Correct 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.
Use gowns, gloves, masks, and strict
aseptic techniques during direct wound care
and provide sterile or freshly laundered bed
linens or gowns.
Option B: Although all techniques listed can
help reduce the risk of infection, only
changing gloves between carrying out
wound care on different parts of the client’s
body can prevent autocontamination.
Depending on the type or extent of wounds
and the choice of wound treatment (open
versus closed), isolation may range from a
simple wound and/or skin to complete or
reverse to reduce the risk of cross-
contamination and exposure to multiple
bacterial flora.
Option C: Prevent skin-to-skin surface
contact (wrap each burned finger or toe
separately; do not allow burned ear to touch
scalp). This identifies the presence of
healing (granulation tissue) and provides for
early detection of burn-wound infection.
Infection in a partial-thickness burn may
cause conversion of burn to full-thickness
injury.
Option D: Emphasize and model good
handwashing techniques for all individuals
coming in contact with the patient. This
prevents cross-contamination and reduces
the risk of acquired infection.
14. Question
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 the resolution
of the fluid shift
Incorrect
Correct Answer: D. As soon as possible
after the resolution of the fluid shift
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.
Option A: The consistent finding in the
literature is that early ambulation can be
safely initiated after lower extremity skin
grafting without compromising graft take if
external compression is applied.
Option B: Following thermal injury, the
innate immune system responds
immediately by stimulating localized and
systemic inflammatory reactions. The innate
immune response participates in activating
the adaptive immune response; however, in
so doing it has an adverse effect on the
burn victim’s ability to mount a vigorous
immune response to invading
microorganisms and, therefore, predisposes
the burn victim to infectious complications.
Option C: Pain control is obtainable by
performing therapies during wound dressing
and debridement, if possible. Analgesics
should also be administered prior to therapy
sessions to encourage participation in
movement activities.
15. Question
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.”
Correct
Correct Answer: B. “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 “takes.” The client
should be prepared for the possibility that
not all grafting procedures will be
successful. Graft survival depends on the
diffusion of nutrients and oxygen from the
wound bed known as imbibition.
Inosculation then follows when the blood
vessels of the graft and from the wound bed
grow together to make end-to-end contact.
Lastly, neovascularization occurs when new
blood vessels grow from the wound bed into
the graft.
Option A: The donor sites will be painful
after the surgery. Silicone gel sheets, along
with pressure dressings, have shown a
dramatic decrease in pain, pruritus, and
scar thickness six months after burn injury.
Option C: There can be scarring in the area
where the skin is removed for grafting. Burn
scars are a common occurrence after skin
grafting and can cause anxiety, depression,
pain, itching, altered pigmentation,
temperature intolerance, and decreased
range of motion secondary to scar
contracture. Scar formation is propagated
by deficiencies in the biosynthetic and
tissue degradation pathway during wound
healing.
Option D: The client is still at risk for
infection. Early failure of graft survival is
attributable to seroma and hematoma
formation, which lifts the graft off the wound
bed, preventing imbibition. Other factors
that lead to graft failure include shearing
forces, edematous tissue, and infected
tissue.
16. Question
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.”
Correct
Correct Answer: D. “I will be fully recovered
when I achieve the highest possible 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.
Option A: Rehabilitation of burns patients is
a continuum of active therapy starting from
admission. There should be no delineation
between an ‘acute phase’ and a
‘rehabilitation phase’ as this idea can
promote the inequality of secondary
disjointed scar management and/or
functional rehabilitation teams.
Option B: The final stage in caring for a
patient with a burn injury is the rehabilitative
stage. This stage starts with the closure of
the burn and ends when the patient has
reached the optimal level of functioning. The
focus is on helping the patient return to a
normal injury-free life. Helping the patient
adjust to the changes the injury has
imposed is also a priority.
Option C: Early compliance is essential to
ensure the best possible long-term outcome
and also to ease pain and assist with
exercise regimes. Patients need to adhere
to a positioning regime in the early stages of
healing and this takes teamwork and
dedication.
17. Question
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.”
Correct
Correct Answer: D. “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. Hypertrophic
burn scars pose a challenge for burn
survivors and providers. In many cases,
they can severely limit a burn survivor’s
level of function, including work and
recreational activities.
Option A: The pressure garment will not
change the angle of the ear attachment to
the head. By applying pressure to the burn
or scar, the face mask keeps the skin soft
and flat during the scar-forming phase of
healing. It helps the face heal with the least
amount of scarring. The transparent face
mask is worn 18-20 hours every day for 8
months to 2 years until the skin graft is
mature.
Option B: 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. A widespread
modality of prevention and treatment of
hypertrophic scarring is the utilization of
pressure garment therapy (PGT).
Option C: Scars will still be present. This
treatment modality continues to be a
clinically accepted practice. It is the most
common therapy used for the treatment and
prevention of abnormal scars after burn
injury particularly in North America, Europe,
and Scandinavia where it is considered
routine practice and regarded as the
preferred conservative management with
reported thinning and better pliability
ranging from 60% to 85%.
18. Question
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
Correct
Correct Answer: B. Impaired Adjustment
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. This stage starts with the
closure of the burn and ends when the
patient has reached the optimal level of
functioning. The focus is on helping the
patient return to a normal injury-free life.
Helping the patient adjust to the changes
the injury has imposed is also a priority.
Option C: Diversional activity for pain is
applicable during the intermediate phase of
the burn injury. Provide diversional activities
appropriate for age and condition. This
helps lessen concentration on pain
experience and refocus attention.
Option D: Imbalanced nutrition is more
appropriate during the emergent and
intermediate phases of the burn injury.
Appropriate guides to proper caloric intake
include 25 kcal/kg body weight, plus 40 kcal
per percentage of TBSA burn in the adult.
As the burn wound heals, the percentage of
burned areas is reevaluated to calculate
prescribed dietary formulas, and appropriate
adjustments are made.
19. Question
Nurse Faith should recognize that fluid shift
in a client with burn injury results from an
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
Correct
Correct Answer: C. Permeability of capillary
walls
In burn, the capillaries and small vessels
dilate, and cell damage causes the release
of a histamine-like substance. The
substance causes the capillary walls to
become more permeable and significant
quantities of fluid are lost.
Option A: The steady intravascular fluid loss
due to these sequences of events requires
sustained replacement of intravascular
volume in order to prevent end-organ
hypoperfusion and ischemia. Reduced
cardiac output is a hallmark in this early
post-injury phase.
Option B: Increase in transcapillary
permeability results in a rapid transfer of
water, inorganic solutes, and plasma
proteins between the intravascular and
interstitial spaces. Subsequently,
intravascular hypovolemia and
haemoconcentration develop and maximum
levels are reached within 12 hours after
injury.
Option D: Disruption of sodium-ATPase
activity presumably causes an intracellular
sodium shift which contributes to
hypovolemia and cellular edema. Heat
injury also initiates the release of
inflammatory and vasoactive mediators.
These mediators are responsible for local
vasoconstriction, systemic vasodilation, and
increased transcapillary permeability.
20. Question
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
Incorrect
Correct Answer: C. Limit the occurrence of
drafts
A client with burns is very sensitive to
temperature changes because heat is lost in
the burn areas. Changes in location,
character, intensity of pain may indicate
developing complications (limb ischemia) or
herald improvement and/or return of nerve
function and sensation.
Option A: Maintain comfortable
environmental temperature, provide heat
lamps, heat-retaining body coverings.
Temperature regulation may be lost with
major burns. External heat sources may be
necessary to prevent chilling.
Option B: Cover wounds as soon as
possible unless open-air exposure burn
care method is required. Temperature
changes and air movement can cause great
pain to exposed nerve endings.
Option D: The major burn patient needs a
body temperature greater than 37 – 37.5ºC
to reach 38.5ºC, to avoid critical
temperature and decrease energy
expenditure, controlling hypercatabolic
state. The recommended ambient
temperature in large burn units is between
28 and 33ºC.
After falling from a 10' ladder, a patient is
brought to the emergency department. The
patient is alert, reports back pain, and
difficulty moving the lower extremities.
Which additional observation is an
indication the patient may be experiencing
neurogenic shock?
A. Cool and pale skin
B. Increased systolic blood pressure
C. Poor skin turgor
D. Bradycardia
D. Bradycardia
A patient who is in hypovolemic shock has
the following clinical signs: Heart rate 120
beats/minute, blood pressure 80/55 and
urine output 20ml/hr. After administering an
IV fluid bolus, which of these signs if noted
by the healthcare provider is the best
indication of improved perfusion?
A. Right atrial pressure increases
B. Systolic blood pressure increases to 85
C. Urine output increases to 30ml/hr
D. Heart rate drops to 100 beats/minute
C. Urine output increases to 30ml/hr
A patient is admitted to the emergency
department after sustaining abdominal
injuries and a broken femur from a motor
vehicle accident. The patient is pale,
diaphoretic, and is not talking coherently.
Vital signs upon admission are temperature
98, heart rate 130 beats/minute, respiratory
rate 34 breaths/minute, blood pressure
50/40. The healthcare provider suspects
which type of shock?
A. Cardiogenic
B. Hypovolemic
C. Neurogenic
D. Distributive
B. Hypovolemic
The healthcare provider is caring for a
patient with a diagnosis of hemorrhagic
pancreatitis. The patient's central venous
pressure (CVP) reading is 2, blood pressure
is 90/50, lung sounds are clear, and jugular
veins are flat. Which of these actions is
most appropriate for the nurse to take?
A. Slow the IV infusion rate
B. Administer dopamine
C. No interventions are needed at this time
D. Increase the IV infusion rate
D. Increase the IV infusion rate
A child is brought to the emergency room by
his mother who reports the child was stung
by a bee while playing in the back yard. The
child has an itchy rash on the face, neck,
and chest. Breathing is labored with audible
wheezing. Which of these medications
should the healthcare provider administer
first?
A. Diphenhydramine
B. Albuterol
C. Epinephrine
D. Dopamine
C. Epinephrine
A patient who has pericarditis related to
radiation therapy, becomes dyspneic, and
has a rapid, weak pulse. Heart sounds are
muffled, and a 12mmHg drop in blood
pressure is noted on inspiration. The
healthcare provider's interventions are
aimed at preventing which type of shock?
A. Distributive
B. Neurogenic
C. Obstructive
D. Cardiogenic
C. Obstructive
An infant was delivered to a mother with a
diagnosis of chorioamnionitis. The infant is
lethargic, tachypneic, and has an axillary
temperature of 96.8. The healthcare
provider suspects septic shock. Which of
these assessments is an indication that this
infant is compensating by increasing cardiac
output?
A. Active precordium
B. Warm, flushed skin
C. Bounding pulses
D. Tachycardia
D. Tachycardia
A patient is being treated for hemorrhagic
shock secondary to multiple rib fractures
and a lacerated liver. Two units of packed
red blood cells have been administered.
Which of these measurements is an
indication the patient has received adequate
volume replacement?
A. Oxygen saturation 90%
B. Increased serum creatinine
C. Decreased right atrial pressure
D. Decreased serum lactate
D. Decreased serum lactate
The healthcare provider is caring for a
patient who has septic shock. Which of
these should the healthcare provider
administer to the patient first?
A. Antibiotics to treat the underlying
infection.
B. Corticosteroids to reduce inflammation.
C. IV fluids to increase intravascular
volume.
D. Vasopressors to increase blood
pressure.
C. IV fluids to increase intravascular volume
A patient who is in cardiogenic shock has a
urine output of 20mL/hr. When further
assessing the patient's renal function, what
additional findings are anticipated? Select
all that apply.
A. Decreased urine specific gravity
B. Increased blood urea nitrogen (BUN)
C. Decreased urine sodium
D. Decreased serum creatinine
B Increased BUN
C. Decreased urine sodium
Which stage of shock is associated with the
worsening of tissue hypoperfusion and
onset of worsening circulatory and
metabolic imbalances, including acidosis?
A. Initial nonprogressive phase
B. Developing phase
C. Progressive stage
D. Irreversible stage
C. Progressive Stage
What are characteristics of the irreversible
stage of shock?
A. The worsening of tissue hypoperfusion
and the onset of worsening circulatory and
metabolic imbalances, including acidosis
B. The body tries to initiate compensatory
mechanisms
C. Nothing can correct the hemodynamic
defect
D. Tissue and cell damage is too great
tissue and necrosis of the tissue will occur
even if the underlying hemodynamic defect
is corrected
D. Tissue and cell damage is too great;
tissue and necrosis of the tissue will occur
even if the underlying hemodynamic defect
is corrected
Your patient is in the progressive stage of
shock. If the shock is not corrected and
tissue hypoxia occurs, what would happen
with the patients metabolism?
A. The tissues will undergo anaerobic
metabolism, creating lactic acid and
lowering the tissue pH
B. Vasomotor reflex of arteriolar constriction
that reduces pooling of blood in the
microcirculation
C. Metabolism would be unaffected by the
lower oxygen level for the 2-3 hours
A. The tissues will undergo anaerobic
metabolism, creating lactic acid and
lowering the tissue pH
Which type of shock is associated with low
blood levels?
A. Hypovolemic shock
B. Septic shock
C. Anaphylactic shock
D. Cardiogenic shock
A. Hypovolemic Shock
You are the charge nurse in an emergency
department (ED) and must assign two staff
members to cover the triage area. Which
team is the most appropriate for this
assignment?
A. An advanced practice nurse and an
experienced LPN/LVN
B. An experienced LPN/LVN and an
inexperienced RN
C. An experienced RN and an
inexperienced RN
D. An experienced RN and a nursing
assistant
C. Triage requires at least one experienced
RN. Pairing an experienced RN with
inexperienced RN provides opportunities for
mentoring. Advanced practice nurses are
qualified to perform triage; however, their
services are usually required in other areas
of the ED. An LPN/LVN is not qualified to
perform the initial patient assessment or
decision making. Pairing an experienced
RN with a nursing assistant is the second
best option, because the assistant can
obtain vital signs and assist in transporting.
You are working in the triage area of an ED,
and four patients approach the triage desk
at the same time. List the order in which you
will assess these patients. a. An
ambulatory, dazed 25-year-old male with a
bandaged head wound b. An irritable infant
with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle,
having pedal pulse and no deformity d. A
50-year-old female with moderate
abdominal pain and occasional vomiting
1. A B D C
2. B A D C
3. C D B A
4. C B A D
2. An irritable infant with fever and
petechiae should be further assessed for
other meningeal signs. The patient with the
head wound needs additional history and
assessment for intracranial pressure. The
patient with moderate abdominal pain is
uncomfortable, but not unstable at this
point. For the ankle injury, medical
evaluation can be delayed 24 - 48 hours if
necessary.
In conducting a primary survey on a trauma
patient, which of the following is considered
one of the priority elements of the primary
survey?
A. Complete set of vital signs
B. Palpation and auscultation of the
abdomen
C. Brief neurologic assessment
D. Initiation of pulse oximetry
C. A brief neurologic assessment to
determine level of consciousness and pupil
reaction is part of the primary survey. Vital
signs, assessment of the abdomen, and
initiation of pulse oximetry are considered
part of the secondary survey.
Question 4 CORRECT
A 56-year-old patient presents in triage with
left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized
into which category?
A. High urgent
B. Urgent
C. Non-urgent
D. Emergent
D. Chest pain is considered an emergent
priority, which is defined as potentially life-
threatening. Patients with urgent priority
need treatment within 2 hours of triage (e.g.
kidney stones). Non-urgent conditions can
wait for hours or even days. (High urgent is
not commonly used; however, in 5-tier
triage systems, High urgent patients fall
between emergent and urgent in terms of
the time lapsing prior to treatment).
The physician has ordered cooling
measures for a child with fever who is likely
to be discharged when the temperature
comes down. Which of the following would
be appropriate to delegate to the nursing
assistant?
A. Assist the child to remove outer clothing.
B. Advise the parent to use acetaminophen
instead of aspirin.
C. Explain the need for cool fluids.
D. Prepare and administer a tepid bath.
A. The nursing assistant can assist with the
removal of the outer clothing, which allows
the heat to dissipate from the child's skin.
Advising and explaining are teaching
functions that are the responsibility of the
RN. Tepid baths are not usually performed
because of potential for rebound and
shivering.
It is the summer season, and patients with
signs and symptoms of heat-related illness
present in the ED. Which patient needs
attention first?
A. An elderly person complains of dizziness
and syncope after standing in the sun for
several hours to view a parade
B. A marathon runner complains of severe
leg cramps and nausea. Tachycardia,
diaphoresis, pallor, and weakness are
observed.
C. A previously healthy homemaker reports
broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse
diaphoresis are observed.
D. A homeless person, poor historian,
presents with altered mental status, poor
muscle coordination, and hot, dry, ashen
skin. Duration of exposure is unknown.
D. The homeless person has symptoms of
heat stroke, a medical emergency, which
increases risk for brain damage. Elderly
patients are at risk for heat syncope and
should be educated to rest in cool area and
avoid future similar situations. The runner is
having heat cramps, which can be managed
with rest and fluids. The housewife is
experiencing heat exhaustion, and
management includes fluids (IV or
parenteral) and cooling measures. The
prognosis for recovery is good.
You respond to a call for help from the ED
waiting room. There is an elderly patient
lying on the floor. List the order for the
actions that you must perform.
a. Perform the chin lift or jaw thrust
maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation
(CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the
crash cart.
BDACE
Establish unresponsiveness first. (The
patient may have fallen and sustained a
minor injury.) If the patient is unresponsive,
get help and have someone initiate the
code. Performing the chin lift or jaw thrust
maneuver opens the airway. The nurse is
then responsible for starting CPR. CPR
should not be interrupted until the patient
recovers or it is determined that heroic
efforts have been exhausted. A crash cart
should be at the site when the code team
arrives; however, basic CPR can be
effectively performed until the team arrives.
The emergency medical service (EMS) has
transported a patient with severe chest pain.
As the patient is being transferred to the
emergency stretcher, you note
unresponsiveness, cessation of breathing,
and no palpable pulse. Which task is
appropriate to delegate to the nursing
assistant?
A. Chest compressions
B. Bag-valve mask ventilation
C. Assisting with oral intubation
D. Placing the defibrillator pads
A. Nursing assistants are trained in basic
cardiac life support and can perform chest
compressions. The use of the bag-valve
mask requires practice and usually a
respiratory therapist will perform this
function. The nurse or the respiratory
therapist should provide PRN assistance
during intubation. The defibrillator pads are
clearly marked; however, placement should
be done by the RN or physician because of
the potential for skin damage and electrical
arcing.
An anxious 24-year-old college student
complains of tingling sensations,
palpitations, and chest tightness. Deep,
rapid breathing and carpal spasms are
noted. What priority nursing action should
you take?
A. Notify the physician immediately.
B. Administer supplemental oxygen.
C. Have the student breathe into a paper
bag.
D. Obtain an order for an anxiolytic
medication
C. The patient is hyperventilating secondary
to anxiety, and breathing into a paper bag
will allow rebreathing of carbon dioxide.
Also, encouraging slow breathing will help.
Other treatments such as oxygen and
medication may be needed if other causes
are identified.
An experienced traveling nurse has been
assigned to work in the ED; however, this is
the nurse's first week on the job. Which
area of the ED is the most appropriate
assignment for the nurse?
A. Trauma team
B. Triage
C. Ambulatory or fast track clinic
D. Pediatric medicine team
C. The fast track clinic will deal with
relatively stable patients. Triage, trauma,
and pediatric medicine should be staffed
with experienced nurses who know the
hospital routines and policies and can
rapidly locate equipment.
A tearful parent brings a child to the ED for
taking an unknown amount of children's
chewable vitamins at an unknown time. The
child is currently alert and asymptomatic.
What information should be immediately
reported to the physician?
A. The ingested children's chewable
vitamins contain iron.
B. The child has been treated several times
for ingestion of toxic substances.
C. The child has been treated several times
for accidental injuries.
D. The child was nauseated and vomited
once at home
A. Iron is a toxic substance that can lead to
massive hemorrhage, coma, shock, and
hepatic failure. Deferoxamine is an antidote
that can be used for severe cases of iron
poisoning. Other information needs
additional investigation, but will not change
the immediate diagnostic testing or
treatment plan.
In caring for a victim of sexual assault,
which task is most appropriate for an
LPN/LVN?
A. Assess immediate emotional state and
physical injuries
B. Collect hair samples, saliva swabs, and
scrapings beneath fingernails.
C. Provide emotional support and
supportive communication.
D. Ensure that the "chain of custody" is
maintained
C. The LPN/LVN is able to listen and
provide emotional support for her patients.
The other tasks are the responsibility of an
RN or, if available, a SANE (sexual assault
nurse examiner) who has received training
to assess, collect and safeguard evidence,
and care for these victims.
You are caring for a victim of frostbite to the
feet. Place the following interventions in the
correct order.
a. Apply a loose, sterile, bulky dressing.
b. Give pain medication.
c. Remove the victim from the cold
environment.
d. Immerse the feet in warm water 100o F to
105o F (40.6o C to 46.1o C)
CBDA
The victim should be removed from the cold
environment first, and then the rewarming
process can be initiated. It will be painful, so
give pain medication prior to immersing the
feet in warmed water.
A patient sustains an amputation of the first
and second digits in a chainsaw accident.
Which task should be delegated to the
LPN/LVN?
A. Gently cleanse the amputated digits with
Betadine solution.
B. Place the amputated digits directly into
ice slurry.
C. Wrap the amputated digits in sterile
gauze moistened with saline.
D. Store the amputated digits in a solution
of sterile normal saline
C. The only correct intervention is C. the
digits should be gently cleansed with normal
saline, wrapped in sterile gauze moistened
with saline, and placed in a plastic bag or
container. The container is then placed on
ice.
A 36-year-old patient with a history of
seizures and medication compliance of
phenytoin (Dilantin) and carbamazepine
(Tegretol) is brought to the ED by the MS
personnel for repetitive seizure activity that
started 45 minutes prior to arrival. You
anticipate that the physician will order which
drug for status epilepticus?
A. PO phenytoin and carbamazepine
B. IV lorazepam (Ativan)
C. IV carbamazepine
D. IV magnesium sulfate
B. IV Lorazepam (Ativan) is the drug of
choice for status epilepticus. Tegretol is
used in the management of generalized
tonic-clonic, absence or mixed type
seizures, but it does not come in an IV form.
PO (per os) medications are inappropriate
for this emergency situation. Magnesium
sulfate is given to control seizures in
toxemia of pregnancy.
You are preparing a child for IV conscious
sedation prior to repair of a facial laceration.
What information should you immediately
report to the physician?
A. The parent is unsure about the child's
tetanus immunization status.
B. The child is upset and pulls out the IV.
C. The parent declines the IV conscious
sedation.
D. The parent wants information about the
IV conscious sedation.
C. Parent refusal is an absolute
contraindication; therefore, the physician
must be notified. Tetanus status can be
addressed later. The RN can restart the IV
and provide information about conscious
sedation; if the parent still not satisfied, the
physician can give more information.
An intoxicated patient presents with slurred
speech, mild confusion, and uncooperative
behavior. The patient is a poor historian but
admits to "drinking a few on the weekend."
What is the priority nursing action for this
patient?
A. Obtain an order for a blood alcohol level.
B. Contact the family to obtain additional
history and baseline information.
C. Administer naloxone (Narcan) 2 - 4 mg
as ordered.
D. Administer IV fluid support with
supplemental thiamine as ordered
D. The patient presents with symptoms of
alcohol abuse and there is a risk for
Wernicke's syndrome, which is caused by a
thiamine deficiency. Multiples drug abuse is
not uncommon; however, there is nothing in
the question that suggests an opiate
overdose that requires naloxone. Additional
information or the results of the blood
alcohol level are part of the total treatment
plan but should not delay the immediate
treatment.
When an unexpected death occurs in the
ED, which of the following tasks is most
appropriate to delegate to the nursing
assistant?
A. Escort the family to a place of privacy.
B. Go with the organ donor specialist to talk
to the family.
C. Assist with postmortem care.
D. Assist the family to collect belongings
C. Postmortem care requires some turning,
cleaning, lifting, etc., and the nursing
assistant is able to assist with these duties.
The RN should take responsibility for the
other tasks to help the family begin the
grieving process. In cases of questionable
death, belongings may be retained for
evidence, so the chain of custody would
have to be maintained.
Following emergency endotracheal
intubation, you must verify tube placement
and secure the tube. List in order the steps
that are required to perform this function?
a. Obtain an order for a chest x-ray to
document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted
ventilation.
d. Confirm that the breath sounds are equal
and bilateral.
CDBA
Auscultating and confirming equal bilateral
breath sounds should be performed in rapid
succession. If the sounds are not equal or if
the sounds are heard over the mid-
epigastric area, tube placement must be
corrected immediately. Securing the tube is
appropriate while waiting for the x-ray study.
A teenager arrives by private car. He is alert
and ambulatory, but this shirt and pants are
covered with blood. He and his hysterical
friends are yelling and trying to explain that
that they were goofing around and he got
poked in the abdomen with a stick. Which of
the following comments should be given first
consideration?
A. "There was a lot of blood and we used
three bandages."
B. "He pulled the stick out, just now,
because it was hurting him."
C. "The stick was really dirty and covered
with mud."
D. "He's a diabetic, so he needs attention
right away
B. An impaled object may be providing a
tamponade effect, and removal can
precipitate sudden hemodynamic
decompensation. Additional history
including a more definitive description of the
blood loss, depth of penetration, and
medical history should be obtained. Other
information, such as the dirt on the stick or
history of diabetes, is important in the
overall treatment plan, but can be
addressed later.
You are assigned to telephone triage. A
patient who was stung by a common honey
bee calls for advice, reports pain and
localized swelling, but denies any
respiratory distress or other systemic signs
of anaphylaxis. What is the action that you
should direct the caller to perform?
A. Call 911.
B. Remove the stinger by scraping.
C. Apply a cool compress.
D. Take an oral antihistamine
B. The stinger will continue to release
venom into the skin, so prompt removal of
the stinger is advised. Cool compresses and
antihistamines can follow. The caller should
be further advised about symptoms that
require 911 assistance.
These patients present to the ED
complaining of acute abdominal pain.
Prioritize them in order of severity.
a. A 35-year-old male complaining of
severe, intermittent cramps with three
episodes of watery diarrhea, 2 hours after
eating
b. A 11-year-old boy with a low-grade fever,
left lower quadrant tenderness, nausea, and
anorexia for the past 2 days
c. A 40-year-old female with moderate left
upper quadrant pain, vomiting small
amounts of yellow bile, and worsening
symptoms over the past week
d. A 56-year-old male with a pulsating
abdominal mass and sudden onset of
pressure-like pain in the abdomen and flank
within the past hour
DBCA
The patient with a pulsating mass has an
abdominal aneurysm that may rupture and
he may decompensate suddenly. The 11-
year-old boy needs evaluation to rule out
appendicitis. The woman needs evaluation
for gallbladder problems that appear to be
worsening. The 35-year-old man has food
poisoning, which is usually self-limiting
The nursing manager decides to form a
committee to address the issue of violence
against ED personnel. Which combination
of employees is best suited to fulfill this
assignment?
A. ED physicians and charge nurses
B. Experienced RNs and experienced
paramedics
C. RNs, LPN/LVNs, and nursing assistants
D. At least one representative from each
group of ED personnel
D. At least one representative from each
group should be included because all
employees are potential targets fro violence
in the ED.
In a multiple-trauma victim, which
assessment finding signals the most serious
and life-threatening condition?
A. A deviated trachea
B. Gross deformity in a lower extremity
C. Decreased bowel sounds
D. Hematuria
A. A deviated trachea is a symptoms of
tension pneumothorax. All of the other
symptoms need to be addressed, but are of
lesser priority.
A patient in a one-car rollover presents with
multiple injuries. Prioritize the interventions
that must be initiated for this patient.
a. Secure/start two large-bore IVs with
normal saline
b. Use the chin lift or jaw thrust method to
open the airway.
c. Assess for spontaneous respirations
d. Give supplemental oxygen per mask.
e. Obtain a full set of vital signs.
f. Remove patient's clothing.
g. Insert a Foley catheter if not
contraindicated.
CBDAEFG
For a multiple trauma victim, many
interventions will occur simultaneously as
team members assist in the resuscitation.
Methods to open the airway such as the
chin lift or jaw thrust can be used
simultaneously while assessing for
spontaneous respirations. However, airway
and oxygenation are priority. Starting IVs for
fluid resuscitation is part of supporting
circulation. (EMS will usually establish at
least one IV in the field.) Nursing assistants
can be directed to take vitals and remove
clothing. Foley catheter is necessary to
closely monitor output.
You are giving discharge instructions to a
woman who has been treated for contusions
and bruises sustained during an episode of
domestic violence. What is your priority
intervention for this patient?
A. Transportation arrangements to a safe
house
B. Referral to a counselor
C. Advice about contacting the police
D. Follow-up appointment for injuries
A. Safety is a priority for this patient, and
she should not return to a place where
violence could occur. The other options are
important for the long term management of
this care.
A patient arrives at the emergency
department complaining of mid-sternal
chest pain. Which of the following nursing
action should take priority?
A. A complete history with emphasis on
preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation.
Answer: C
The priority nursing action for a patient
arriving at the ED in distress is always
assessment of vital signs. This indicates the
extent of physical compromise and provides
a baseline by which to plan further
assessment and treatment. A thorough
medical history, including onset of
symptoms, will be necessary and it is likely
that an electrocardiogram will be performed
as well, but these are not the first priority.
Similarly, chest exam with auscultation may
offer useful information after vital signs are
assessed.
Emergency department triage is an
important nursing function. A nurse working
the evening shift is presented with four
patients at the same time. Which of the
following patients should be assigned the
highest priority?
A. A patient with low-grade fever, headache,
and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on
the left foot, with swelling and bruising
following a running accident.
C. A patient with abdominal and chest pain
following a large, spicy meal.
D. A child with a one-inch bleeding
laceration on the chin but otherwise well
after falling while jumping on his bed.
Answer: C
Emergency triage involves quick patient
assessment to prioritize the need for further
evaluation and care. Patients with trauma,
chest pain, respiratory distress, or acute
neurological changes are always classified
number one priority. Though the patient with
chest pain presented in the question
recently ate a spicy meal and may be
suffering from heartburn, he also may be
having an acute myocardial infarction and
require urgent attention. The patient with
fever, headache and muscle aches (classic
flu symptoms) should be classified as non-
urgent. The patient with the foot injury may
have sustained a sprain or fracture, and the
limb should be x-rayed as soon as is
practical, but the damage is unlikely to
worsen if there is a delay. The child's chin
laceration may need to be sutured but is
also non-urgent.
A nurse employed in an emergency
department is assigned to triage clients
arriving to the emergency room for
treatment on the evening shift. The nurse
should assign highest priority to which of the
following clients?
a) a client complaining of muscle aches, a
headache, and malaise
b) a client who twisted her ankle when she
fell while rollerblading
c) a client with a minor laceration on the
index finger sustained while cutting an
eggplant
d) a client with chest pain who states that he
just ate pizza that was made with a very
spicy sauce
D rate
- In an emergency department, triage
involves brief client assessment to classify
clients according to their need for care and
includes establishing priorities of care. The
type of illness or injury, the severity of the
problem, and the resources available
govern the process. Clients with trauma,
chest pain, severe respiratory distress or
cardiac arrest, limb amputation, acute
neurological deficits, and those who have
sustained chemical splashes to the eyes are
classified as emergent and are the number
1 priority. Clients with conditions such as a
simple fracture, asthma without respiratory
distress, fever, hypertension, abdominal
pain, or a renal stone have urgent needs
and are classified as number 2 priority.
Clients with conditions such as a minor
laceration, sprain, or cold symptoms are
classified as nonurgent and are the number
3 priority.
A patient arrives in the emergency
department with symptoms of myocardial
infarction, progressing to cardiogenic shock.
Which of the following symptoms should the
nurse expect the patient to exhibit with
cardiogenic shock?
A. Hypertension.
B. Bradycardia.
C. Bounding pulse.
D. Confusion.
D. Confusion
Cardiogenic shock severely impairs the
pumping function of the heart muscle,
causing diminished blood flow to the organs
of the body. This results in diminished brain
function and confusion, as well as
hypotension, tachycardia, and weak pulse.
Cardiogenic shock is a serious complication
of myocardial infarction with a high mortality
What is the treatment of choice to correct
Hypovolemic Shock?
A. Have the patient drink a large bottle of
Gatorade.
B. Replace fluids intravenously as quickly
as possible.
C. Administer a vasopressor
D. All of the above.
B. Replace fluids intravenously as quickly
as possible
What causes decreased BP in neurogenic
shock?
A. Movement of fluid into the cells
B. Movement of fluid into the vasculature
C. Disrupted SNS communication
D. Polyuria
C. Disrupted SNS communication
What class of drug is typically used to treat
neurogenic shock?
A. Beta-blocker
B. Calcium-channel blocker
C. Loop diuretic
D. Vasopressor
D. Vasporessor
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
D. Full thickness
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).
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
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; pain
present and high).
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
C. The danger of an overdose during fluid
remobilization is reduced
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.
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
D. Vitamin 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.
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.
C. The burned areas include the hands and
perineum
Burns of the perineum increase the risk for
sepsis. Burns of the hands require special
attention to ensure the best functional
outcome.
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."
C. Decrease hydrochloric acid production
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.
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
C. During fluid remobilization
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.
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
C. Cherry red color to mucous membranes
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.
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.
C. Capillary refill is slow in the digits and the
distal pulse is absent
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.
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
D. Hemoglobin S electrophoresis
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.
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
B. Crystalloids
Although not universally true, most fluid
resuscitation for burn injuries starts with
crystalloid solutions, such as normal saline
and Ringer's lactate. The burn client rarely
requires blood during the emergent phase
unless the burn is complicated by another
injury that involved hemorrhage. 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.
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
B. Loosen 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.
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
B. Notify the emergency team
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.
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
B. Document
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.
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
A. Fluid shift
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.
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
B. Document
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, and it is not the
highest priority of care at this time.
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
A. Increased urine and decreased urine
specific gravity
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.
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
C. Risk for disuse syndrome
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
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%
B. Potassium 7.5
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.
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
B. Heart rate and rhythm
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.
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?"
D. Place and space
The risk for inhalation injury is greatest
when flame burns occur indoors in small,
poorly ventilated rooms. although smoking
increases the risk for some problems, it
does not predispose the client for an
inhalation injury.

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
C. oxygen saturation is 97%
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.
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."
B. When 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 great risk for
infection as long as any area of skin is
open.
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
C. MI 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 failure and pulmonary
edema during fluid resuscitation
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
C. Auscultate breath sounds
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.
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
A. Handwashing upon entering room

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.
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.
C. Turn head 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 client has severe burns around the right
hip. Which position is most important to be
emphasized by the nurse that the client
maintain 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
D. 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 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
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
D. Increased 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
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.
D. Notify burn emergency team
These findings are associated with systemic
gram-negative infection and sepsis. This is
a medical emergency and requires prompt
attention
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.
A. Changing gloves between wound care on
different parts of the 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
difference parts of the client's body can
prevent autocontamination.
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
D. As soon as possible after fluid shift
Regular, progressive ambulation is initiated
for all burn clients who do not have
contraindications 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.
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."
B. Because it is my own skin
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.
Which statement by the client indicates
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."
D. I will achieve highest level of functioning
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.
Which statement made by the client with
facial burns who has been prescribed to
wear a facial mask pressure garment
indicates 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."
D. Facial scars should be less severe
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.
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
B. Impaired adjustment
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. By
the rehabilitation phase, acute pain from the
injury or its treatment is no longer a
problem.
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
C. Permeability of capillary walls
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.
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
C. Limit drafts
A Client with burns is very sensitive to
temperature changes because heat is loss
in the burn areas.
A client who has had a full-thickness burn is
being discharged from the hospital. Which
information is most important for the nurse
to provide prior to discharge?
A. How to maintain home smoke detectors
B. Joining a community reintegration
program
C. Learning to perform dressing changes
D. Options available for scar removal
C. Dressing changes
Critical for the goal of progression toward
independence for the client is teaching
clients and family members to perform care
tasks such as dressing changes. All the
other distractors are important in the
rehabilitation stage. However, dressing
changes have priority.
A client who is admitted after a thermal burn
injury has the following vital signs: blood
pressure, 70/40; heart rate, 140 beats/min;
respiratory rate, 25/min. He is pale in color
and it is difficult to find pedal pulses. Which
action will the nurse take first?
A. Begin intravenous fluids
B. Check the pulses with a Doppler device
C. Obtain a complete blood count (CBC)
D. Obtain an electrocardiogram (ECG)
A. Begin IV fluids
Hypovolemic shock is a common cause of
death in the emergent phase of clients with
serious injuries. Fluids can treat this
problem. An ECG and CBC will be taken to
ascertain if a cardiac or bleeding problem is
causing these vital signs. However these
are not actions that the nurse would take
immediately. Checking pulses would
indicate perfusion to the periphery but this is
not an immediate nursing action.
A client who was burned has crackles and a
respiratory rate of 40/min, and is coughing
up blood-tinged sputum. What action will the
nurse take first?
A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position
D. 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.
On assessment, the nurse notes that the
client has burns inside the mouth and is
wheezing. Several hours later, the wheezing
is no longer heard. What is the nurse's next
action?
A. Documenting the findings
B. Loosening any dressings on the chest
C. Raising the head of the bed
D. Preparing for intubation
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.
The client with a full-thickness burn is being
discharged to home after a month in the
hospital. His wounds are minimally opened
and he will be receiving home care. Which
nursing diagnosis has the highest priority?
A. Acute Pain
B. Deficient Diversional Activity
C. Impaired Adjustment
D. Imbalanced Nutrition: Less than Body
Requirements
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.
The client with facial burns asks the nurse if
he will ever look the same. Which response
is best for the nurse to provide?
A. "With reconstructive surgery, you can
look the same."
B. "We can remove the scars with the use
of a pressure dressing."
C. "You will not look exactly the same."
D. "You shouldn't start worrying about your
appearance right now."
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.
The client with open burn wounds begins to
have diarrhea. The client is found to have a
below-normal temperature, with a white
blood cell count of 4000/mm3. Which is the
nurse's best action?
A. Continuing to monitor the client
B. Increasing the temperature in the room
C. Increasing the rate of the intravenous
fluids
D. Preparing to do a workup for sepsis
D. 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.
The nurse provides wound care for a client
48 hours after a burn injury. To achieve the
desired outcome of the procedure, which
nursing action will be carried out first?
A. Applies silver sulfadiazine (Silvadene)
ointment
B. Covers the area with an elastic wrap
C. Places a synthetic dressing over the area
D. Removes loose nonviable tissue
D. Remove 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.
Which patient is at risk for compartment
syndrome due to a burn?
A. A 25 year old with circumferential burn of
the anterior and posterior left arm.
B. A 7 year old with a burn of the left and
right ear.
C. A 55 year old with an electrical burn on
the neck.
D. A 15 year old with a chemical burn to the
right foot
A. anterior and posterior arm
Circumferential burns of the extremities
produce a tourniquet like effect and leads to
vascular problems.
As a nurse working on a burn unit, which of
your patients are at high risk for internal
tissue damage?
A. Patient in room 2101 with an electrical
burn on torso.
B. Patient in room 2106 with a radiation
burn on the abdomen.
C. Patient in room 2103 with a thermal burn
to peritoneal area.
D. Patient in room 2101 with a chemical
burn to face.
A. electrical burn
Electrical burns are caused by heat
generated by electrical current which is
transferred through the body. This current
burns the skin but also affects internal
tissue as well.
A preceptor is observing a nursing student
provide care to a patient with major burns to
the face and head. What nursing
intervention does the student perform
correctly?
A. Elevates the head of the bead at 30'.
B. Uses gloves and face mask when
providing care.
C. Places the patient in trendelenburg
position.
D. Assist the patient with eating food tray
A. elevate HOB
Due to edema and respiratory issues patient
with facial burns should have the HOB at
30'. In additon, strict isolation protocol is
implemented because they patient is at high
risk for infection ( gloves and facial mask
are not sufficent enough)
A patient with 55% burns is groaing out in
pain and rates pain 10 on 1-10 scale. You
have PRN orders for the following
medications. What is the best option for this
patient?
A. IV Morphine
B. Oral Lortab liquid suspension
C. IM Demerol
D. Subcutaneous Demerol
A. IV morphine
IV route is the best option when a patient
has burns. If a medication is given IM or
subq, hypovolemia may disrupt absorption.
In addition, oral route should be avoid due
to potential GI dysfunction.
A patient is being discharge after having
autografting. What would you include in
your discharge education?
A. Keep the site free from pressure and
keep the site lubricated.
B. Encourage for the site to be exposed to
sunlight to promoted melanin production.
C. Avoid using splints or any type of support
garment.
D. Encourage weight-bearing exercise
every 4 to 6 hours.
A. Keep site from pressure and keep
lubricated
The patient should avoid the sunlight due to
increase risk of sunburn to delicate skin. In
addition, the patient should avoid weight-
bearing activites to prevent damage to the
newly grafted skin. It is best to encourage
splints and support garments to protect the
skin during acitiviy.
A patient is undergoing a escharotomy.
Which of the following is correct about the
procedure?
A. It is performed on circumferential burns
and is usually performed at bedside without
anesthesia.
B. It is performed on radiation burns and
requires general anesthesia.
C. It is performed if tissue perfusion does
NOT return after a fasciotomy.
D. None of the options are correct.
A
Escharotomy are performed at the beside
without anesthia because the nerves are
already damaged. It is first performed when
a patient has a circumferential burn and if
tissue perfusion fails to return a fasciotomy
is performed in the operating room.
A patient with a spinal cord injury (SCI)
complains about a severe throbbing
headache that suddenly started a short time
ago. Assessment of the patient reveals
increased blood pressure (168/94) and
decreased heart rate (48/minute),
diaphoresis, and flushing of the face and
neck. What action should you take first?
A. Administer the ordered acetaminophen
(Tylenol).
B. Check the Foley tubing for kinks or
obstruction.
C. Adjust the temperature in the patient's
room.
D. Notify the physician about the change in
status
B. Foley
These signs and symptoms are
characteristic of autonomic dysreflexia, a
neurologic emergency that must be
promptly treated to prevent a hypertensive
stroke. The cause of this syndrome is
noxious stimuli, most often a distended
bladder or constipation, so checking for
poor catheter drainage, bladder distention,
or fecal impaction is the first action that
should be taken. Adjusting the room
temperature may be helpful, since too cool
a temperature in the room may contribute to
the problem. Tylenol will not decrease the
autonomic dysreflexia that is causing the
patient's headache. Notification of the
physician may be necessary if nursing
actions do not resolve symptoms. Focus:
Prioritization
A patient with a spinal cord injury at level
C3-4 is being cared for in the ED. What is
the priority assessment?
A. Determine the level at which the patient
has intact sensation.
B. Assess the level at which the patient has
retained mobility.
C. Check blood pressure and pulse for
signs of spinal shock.
D. Monitor respiratory effort and oxygen
saturation level
D. Respiratory
The first priority for the patient with an SCI
is assessing respiratory patterns and
ensuring an adequate airway. The patient
with a high cervical injury is at risk for
respiratory compromise because the spinal
nerves (C3 - 5) innervate the phrenic nerve,
which controls the diaphragm. The other
assessments are also necessary, but not as
high priority. Focus: Prioritization
You are pulled from the ED to the
neurologic floor. Which action should you
delegate to the nursing assistant when
providing nursing care for a patient with
SCI?
A. Assess patient's respiratory status every
4 hours.
B. Take patient's vital signs and record
every 4 hours.
C. Monitor nutritional status including calorie
counts.
D. Have patient turn, cough, and deep
breathe every 3 hours
B. Vital signs
The nursing assistant's training and
education include taking and recording
patient's vital signs. The nursing assistant
may assist with turning and repositioning
the patient and may remind the patient to
cough and deep breathe but does not teach
the patient how to perform these actions.
Assessing and monitoring patients require
additional education and are appropriate to
the scope of practice for professional
nurses. Focus: Delegation/supervision
You are helping the patient with an SCI to
establish a bladder-retraining program.
What strategies may stimulate the patient to
void? (Choose all that apply).
A. Stroke the patient's inner thigh.
B. Pull on the patient's pubic hair.
C. Initiate intermittent straight
catheterization.
D. Pour warm water over the perineum.
E. Tap the bladder to stimulate detrusor
muscle
A, B, D, E
All of the strategies, except straight
catheterization, may stimulate voiding in
patients with SCI. Intermittent bladder
catheterization can be used to empty the
patient's bladder, but it will not stimulate
voiding.
The patient with a cervical SCI has been
placed in fixed skeletal traction with a halo
fixation device. When caring for this patient
the nurse may delegate which action (s) to
the LPN/LVN? (Choose all that apply).
A. Check the patient's skin for pressure
form device.
B. Assess the patient's neurologic status for
changes.
C. Observe the halo insertion sites for signs
of infection.
D. Clean the halo insertion sites with
hydrogen peroxide
A, C, D
Checking and observing for signs of
pressure or infection are within the scope of
practice of the LPN/LVN. The LPN/LVN also
has the appropriate skills for cleaning the
halo insertion sites with hydrogen peroxide.
Neurologic examination requires additional
education and skill appropriate to the
professional RN
You are preparing a nursing care plan for
the patient with SCI including the nursing
diagnosis Impaired Physical Mobility and
Self-Care Deficit. The patient tells you, "I
don't know why we're doing all this. My life's
over." What additional nursing diagnosis
takes priority based on this statement?
A. Risk for Injury related to altered mobility
B. Imbalanced Nutrition, Less Than Body
Requirements
C. Impaired Adjustment to Spinal Cord
Injury
D. Poor Body Image related to
immobilization
C. Impaired Adjustment
The patient's statement indicates
impairment of adjustment to the limitations
of the injury and indicates the need for
additional counseling, teaching, and
support. The other three nursing diagnoses
may be appropriate to the patient with SCI,
but they are not related to the patient's
statement
A nurse is performing an assessment on a
client who has a suspected spinal cord
injury. Which of the following is the priority
nursing assessment?
a) pain level
b) mobility level
c) respiratory status
d) pupillary response
C. Respiratory status
All of these assessments would be
performed on a client with a suspected
spinal cord injury. However, respiratory
status is the priority.
When admitting a patient who has a history
of paraplegia as a result of a spinal cord
injury, the nurse will plan to
a. check the patient for urinary incontinence
every 2 hours to maintain skin integrity.
b. assist the patient to the toilet on a
scheduled basis to help ensure bladder
emptying.
c. use intermittent catheterization on a
regular schedule to avoid the risk of
infection.
d. ask the patient about the usual urinary
pattern and measures used for bladder
control
D. ask about usual urinary patterns
A patient with a neck fracture at the C5 level
is admitted to the intensive care unit (ICU)
following initial treatment in the emergency
room. During initial assessment of the
patient, the nurse recognizes the presence
of spinal shock on finding
a. hypotension, bradycardia, and warm
extremities.
b. involuntary, spastic movements of the
arms and legs.
c. the presence of hyperactive reflex activity
below the level of the injury.
d. flaccid paralysis and lack of sensation
below the level of the injury
D. Flaccid paralysis and lack of sensation
A patient with a T1 spinal cord injury is
admitted to the intensive care unit (ICU).
The nurse will teach the patient and family
that
a. use of the shoulders will be preserved.
b. full function of the patient's arms will be
retained.
c. total loss of respiratory function may
occur temporarily.
d. elevations in heart rate are common with
this type of injury.
B. Full function of the patients arms will be
retained
The health care provider orders
administration of IV methylprednisolone
(Solu-Medrol) for the first 24 hours to a
patient who experienced a spinal cord injury
at the T10 level 3 hours ago. When
evaluating the effectiveness of the
medication the nurse will assess
a. blood pressure and heart rate.
b. respiratory effort and O2 saturation.
c. motor and sensory function of the legs.
d. bowel sounds and abdominal distension
C. Motor and sensory function of the legs
A patient with a paraplegia resulting from a
T10 spinal cord injury has a neurogenic
reflex bladder. When the nurse develops a
plan of care for this problem, which nursing
action will be most appropriate?
a. Teaching the patient how to self-
catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the
bladder
d. Catheterization for residual urine after
voiding
A. teaching on self-cath measures
A patient with a history of a T2 spinal cord
tells the nurse, "I feel awful today. My head
is throbbing, and I feel sick to my stomach."
Which action should the nurse take first?
a. Notify the patient's health care provider.
b. Check the blood pressure (BP).
c. Give the ordered antiemetic.
d. Assess for a fecal impaction.
B. Check BP
Rationale: The BP should be assessed
immediately in a patient with an injury at the
T6 level or higher who complains of a
headache to determine whether autonomic
dysreflexia is causing the symptoms,
including hypertension. Notification of the
patient's health care provider is appropriate
after the BP is obtained. Administration of
an antiemetic is indicated after autonomic
dysreflexia is ruled out as the cause of the
nausea. The nurse may assess for a fecal
impaction, but this should be done after
checking the BP and lidocaine jelly should
be used to prevent further increases in the
BP
The nurse discusses long-range goals with
a patient with a C6 spinal cord injury. An
appropriate patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently
when in bed.
d. pushes a manual wheelchair on flat,
smooth surfaces
D. Pushes manual wheelchair
A 26-year-old patient with a C8 spinal cord
injury tells the nurse, "My wife and I have
always had a very active sex life, and I am
worried that she may leave me if I cannot
function sexually." The most appropriate
response by the nurse to the patient's
comment is to
a. advise the patient to talk to his wife to
determine how she feels about his sexual
function.
b. tell the patient that sildenafil (Viagra)
helps to decrease erectile dysfunction in
patients with spinal cord injury.
c. inform the patient that most patients with
upper motor neuron injuries have reflex
erections.
d. suggest that the patient and his wife work
with a nurse specially trained in sexual
counseling
D. Sexual counseling
A 25-year-old patient has returned home
following extensive rehabilitation for a C8
spinal cord injury. The home care nurse
visits and notices that the patient's spouse
and parents are performing many of the
activities of daily living (ADLs) that the
patient had been managing during
rehabilitation. The most appropriate action
by the nurse at this time is to
a. tell the family members that the patient
can perform ADLs independently.
b. remind the patient about the importance
of independence in daily activities.
c. recognize that it is important for the
patient's family to be involved in the
patient's care and support their activities.
d. develop a plan to increase the patient's
independence in consultation with the with
the patient, spouse, and parents
D. Develop POC to increase independence
When caring for a patient who was admitted
24 hours previously with a C5 spinal cord
injury, which nursing action has the highest
priority?
a. Continuous cardiac monitoring for
bradycardia
b. Administration of methylprednisolone
(Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression
devices to both legs
C. Assessment of respiratory rate and depth
My BP is normal, HR >100, RR >20, skin is
cold and clammy, slight decrease to urinary
output, confused, and respiratory alkalosis.
What stage of shock
Pre-Shock
My BP systolic BP <80-90, HR 100-150,
rapid shallow respirations with crackles
heard on auscultation, skin has become
mottled with petechiae, urine output has
become severely decreased, I'm lethargic
and have gone in to metabolic acidosis.
What stage of shock
Shock
I'm no longer able to breathe on my own,
my HR is erractic or I've gone in to asystole,
my skin has become jaundiced, I'm anuric,
become unresponsive and now have
profound acidosis. What stage of shock
End-Organ
The nurse is triaging four clients injured in a
train derailment. Which client should receive
priority treatment?
A 42-year-old with dyspnea and chest
asymmetry
b 17-year-old with a fractured arm
C 4-year-old with facial lacerations
D.A 30-year-old with blunt abdominal
trauma
Answer A is correct. Following the ABCDs
of basic emergency care, the client
withdyspnea and asymmetrical chest should
be cared for first because thesesymptoms
are associated with flail chest. Answer D is
incorrect because he shouldbe cared for
second because of the likelihood of organ
damage and bleeding.Answer B is incorrect
because he should be cared for after the
client withabdominal trauma. Answer C is
incorrect because he should receive care
lastbecause his injuries are less severe
Direct pressure to a deep laceration on the
client's lower leg has failed to stop the
bleeding. The nurse's next action should be
to:
A. Place a tourniquet proximal to the
laceration.
B. Elevate the leg above the level of the
heart.
C. Cover the laceration and apply an ice
compress
D. Apply pressure to the femoral artery
Answer B is correct. If bleeding does not
subside with direct pressure, the
nurseshould elevate the extremity above the
level of the heart. Answers A and D aredone
only if other measures are ineffective, so
they are incorrect. Answer C wouldslow the
bleeding but will not stop it, so it's incorrect
The nurse is preparing to administer
Lactate Ringer's to a client with
hypovolemic shock. Which intervention is
important in helping to stabilize the client's
condition?
A. Warming the intravenous fluids
B. Determining whether the client can take
oral fluids
C. Checking for the strength of pedal pulses
D. Obtaining the specific gravity of the urine
A. Warming the intravenous fluids
An unresponsive client is admitted to the
emergency room with a history of
diabetes mellitus. The client's skin is cold
and clammy, and the blood pressure
reading is 82/56. The first step in
emergency
treatment of the client's symptoms
would be:
A.Checking the client's blood sugar
B. Administering intravenous dextrose
C. Intubation and ventilator support
D. Administering regular insulin
Answer A is correct. The client has
symptoms of insulin shock and the first step
is
to check the client's blood sugar. If
indicated, the client should be treated with
intravenous dextrose. Answer B is wrong
because it is not the first step the nurse
should take. Answer C is wrong because it
does not apply to the client's
symptoms. Answer D is wrong because it
would be used for diabetic ketoacidosis,not
insulin shock.
A client with a history of severe depression
has been brought to the emergency room
with an overdose of barbiturates. The nurse
should pay careful attention to
the client's:
A. Urinary output
B. Respirations
C. Temperature
D. Verbal responsiveness
Answer B is correct. Barbiturate overdose
results in central nervous system
depression, which leads to respiratory
failure. Answers A and C are important to
the client's overall condition but are not
specific to the question, so they are
incorrect. The use of barbiturates results in
slow, slurred speech, so answer D is
expected, and therefore incorrect.
A client is to receive antivenin following a
snake bite. Before administering the
antivenin, the nurse should give priority to:
A. Administering a local anesthetic
B. Checking for an allergic response
C. Administering an anxiolytic
D.Withholding fluids for 6 - 8 hours
Answer B is correct. The nurse should
perform the skin or eye test before
administering antivenin. Answers A and D
are unnecessary and therefore incorrect.
Answer C would help calm the client but is
not a priority before giving the antivenin,
making it incorrect.
You are working in the triage area of an ED,
and four patients approach the triage desk
at the sametime. List the order in which you
will assess these patients.
a. An ambulatory, dazed 25-year-old male
with a bandaged head wound
b. An irritable infant with a fever, petechiae,
and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle,
having pedal pulse and no deformity
d. A 50-year-old female with moderate
abdominal pain and occasional vomiting
Answer: B, A, D, C
- insensitive to touch
An irritable infant with fever and petechiae
should be further assessed for other
meningeal signs. The patient with the head
wound needs additional history and
assessment for intracranial pressure. The
patient with moderate abdominal pain is
uncomfortable, but not unstable at this
point. For the ankle injury, medical
evaluation can be delayed 24-48 hours if
necessary
A 56-year-old patient presents in triage with
left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized
into which category?
a. High urgent
b. Urgent
c. Non-urgent
d. Emergent
Answer: D
-
Chest pain is considered an emergent
priority, which is defined as potentially life-
threatening. Patients with urgent priority
need treatment within 2 hours of triage (e.g.
kidney stones).Non-urgent conditions can
wait for hours or even days. (High urgent is
not commonly used; however, in5-tier triage
systems, High urgent patients fall between
emergent and urgent in terms of the
timelapsing prior to treatment).
The emergency service team brings a client
to the emergency department. The client
was found lying in an alley near a Dumpster
by a policeman, who reports that the client
is a homeless victim. An assessment is
performed, and the client is suspected of
having frostbite of the hands. Which of the
following findings would the nurse note in
this condition?
a) a white appearance to the skin that is
b) a pink edematous hand
c) black fingertips surrounded by an
erythematous rash
d) resd skin with edema in the nail beds
A
- Assessment findings in frostbite include a
white or blue appearance, and the skin will
be hard, cold, and insensitive to touch. As
thawing occurs, the skin becomes flushed,
blisters or blebs develop, or tissue edema
appears. Gangrene develops in 9 to 15
days
An emergency department nurse prepares
to treat a client who has frostbite of the toes
from prolonged exposure during an ice-
fishing trip. Which of the following would the
nurse anticipate to be prescribed for this
condition?
a) rapid rewarming of the toes in hot water
b) rapid and continuous rewarming of the
toes in a warm water bath until flushing of
the skin occurs
c) rapid and continuous alternating cold and
hot soaks of the toes
d) rapid rewarming of the toes by soaking in
cold water for 45 minutes
B which of the following?
- Acute frostbite is ideally treated with rapid
and continuous rewarming of the tissue in a
water bath for 15 to 20 minutes or until
flushing of the skin occurs. Slow thawing or
interrupted periods of warmth are avoided
because this can contribute to increased
cellular damage. Thawing can cause
considerable pain, and the nurse would
administer analgesics as prescribed.
Which of the following strategies is NOT
effective for prevention of Lyme disease?
A. Insect repellant on the skin and clothes
when in a Lyme endemic area.
B. Long sleeved shirts and long pants.
C. Prophylactic antibiotic therapy prior to
anticipated exposure to ticks.
D. Careful examination of skin and hair for
ticks following anticipated exposure.
C. Prophylactic antibiotic
A parent calls the pediatric clinic and is
frantic about the bottle of cleaning fluid her
child drank 20 minutes. Which of the
following is the most important instruction
the nurse can give the parent?
A: This too shall pass.
B: Take the child immediately to the ER
C: Contact the Poison Control Center
quickly
D: Give the child syrup of ipecac
(C) The poison control center will have an
exact plan of action for this child.
A mother arrives at the emergency
department with her child, stating that she
just found the child sitting on the floor next
to an empty bottle of aspirin. On
assessment, the nurse notes that the child
is drowsy but conscious. The nurse
anticipates that the physician will prescribe
a) ipecac syrup
b) activated charcoal
c) magnesium citrate
d) magnesium sulfate
B
- Whereas ipecac is administered to induce
vomiting in certain poisoning situations, it is
not recommended as the initial treatment in
the hospital setting for ingestion of
salicylates. This is because ipecac does not
totally remove the poison from the child's
system. In this situation, the child is
conscious and the ingested substance
(aspirin) would not damage the esophagus
or lungs from vomiting. However, activated
charcoal would be prescribed as an antidote
in this poisoning situation, because its
action is to absorb ingested toxic
substances and thus decrease absorption.
Options C and D are unrelated to treatment
for this occurrence.
The nurse is caring for a client admitted with
spinal cord injury. The nurse minimizes the
risk of compounding the injury most
effectively by:
A. Keeping the client on a stretcher
B. Logrolling the client on a firm mattress
C. Logrolling the client on a soft mattress
D. Placing the client on a Stryker frame
D. Stryker frame
Spinal immobilization is necessary after
spinal cord injury to prevent further damage
and insult to the spinal cord. Whenever
possible, the client is placed on a Stryker
frame, which allows the nurse to turn the
client to prevent complications of immobility,
while maintaining alignment of the spine. If
a Stryker frame is not available, a firm
mattress with a bed board should be used.
A 20-year-old client who fell approximately
30' is unresponsive and breathless. A
cervical spine injury is suspected. How
should the first-responder open the client's
airway for rescue breathing?
A. By inserting a nasopharyngeal airway
B. By inserting a oropharyngeal airway
C. By performing a jaw-thrust maneuver
D. By performing the head-tilt, chin-lift
maneuver
C. Jaw-thrust maneuver
If the client has a suspected cervical spine
injury, a jaw-thrust maneuver should be
used to open the airway. If the tongue or
relaxed throat muscles are obstructing the
airway, a nasopharyngeal or oropharyngeal
airway can be inserted; however, the client
must have spontaneous respirations when
the airway is open. The head-tilt, chin-lift
maneuver requires neck hyperextension,
which can worsen the cervical spine injury.
A client comes into the ER after hitting his
head in an MVA. He's alert and oriented.
Which of the following nursing interventions
should be done first?
A. Assess full ROM to determine extent of
injuries
B. Call for an immediate chest x-ray
C. Immobilize the client's head and neck
D. Open the airway with the head-tilt chin-lift
maneuver
C. Immobilize head and neck
All clients with a head injury are treated as if
a cervical spine injury is present until x-rays
confirm their absence. ROM would be
contraindicated at this time. There is no
indication that the client needs a chest x-
ray. The airway doesn't need to be opened
since the client appears alert and not in
respiratory distress. In addition, the head-tilt
chin-lift maneuver wouldn't be used until the
cervical spine injury is ruled out.
Which of the following interventions
describes an appropriate bladder program
for a client in rehabilitation for spinal cord
injury?
A. Insert an indwelling urinary catheter to
straight drainage
B. Schedule intermittent catheterization
every 2 to 4 hours
C. Perform a straight catheterization every 8
hours while awake
D. Perform Crede's maneuver to the lower
abdomen before the client voids
B. Intermittent cath Q2-4H
Intermittent catherization should begin every
2 to 4 hours early in the treatment. When
residual volume is less than 400 ml, the
schedule may advance to every 4 to 6
hours. Indwelling catheters may predispose
the client to infection and are removed as
soon as possible. Crede's maneuver is not
used on people with spinal cord injury.
When discharging a client from the ER after
a head trauma, the nurse teaches the
guardian to observe for a lucid interval.
Which of the following statements best
described a lucid interval?
A. An interval when the client's speech is
garbled.
B. An interval when the client is alert but
can't recall recent events.
C. An interval when the client is oriented but
then becomes somnolent.
D. An interval when the client has a
"warning" symptom, such as an odor or
visual disturbance.
C.
A lucid interval is described as a brief period
of unconsciousness followed by alertness;
after several hours, the client again loses
consciousness. Garbled speech is known
as dysarthria. An interval in which the client
is alert but can't recall recent events is
known as amnesia. Warning symptoms or
auras typically occur before seizures.
A client with a spinal cord injury is prone to
experiencing autonomic dysreflexia. The
nurse would avoid which of the following
measures to minimize the risk of
recurrence?
A. Strict adherence to a bowel retraining
program
B. Limiting bladder catheterization to once
every 12 hours
C. Keeping the linen wrinkle-free under the
client
D. Preventing unnecessary pressure on the
lower limbs
B. Limiting bladder cath to once Q12H
The most frequent cause of autonomic
dysreflexia is a distended bladder. Straight
catherization should be done every 4 to 6
hours, and Foley catheters should be
checked frequently to prevent kinks in the
tubing. Constipation and fecal impaction are
other causes, so maintaining bowel
regularity is important. Other causes include
stimulation of the skin from tactile, thermal,
or painful stimuli. The nurse administers
care to minimize risk in these areas.
A nurse assesses a client who has episodes
of autonomic dysreflexia. Which of the
following conditions can cause autonomic
dysreflexia?
A. Headache
B. Lumbar spinal cord injury
C. Neurogenic shock
D. Noxious stimuli
D. Noxious Stimuli
Noxious stimuli, such as a full bladder, fecal
impaction, or a decub ulcer, may cause
autonomic dysreflexia. A headache is a
symptom of autonomic dysreflexia, not a
cause. Autonomic dysreflexia is most
commonly seen with injuries at T10 or
above. Neurogenic shock isn't a cause of
dysreflexia.
After falling 20', a 36-year-old man sustains
a C6 fracture with spinal cord transaction.
Which other findings should the nurse
expect?
A. Quadriplegia with gross arm movement
and diaphragmatic breathing
B. Quadriplegia and loss of respiratory
function
C. Paraplegia with intercostal muscle loss
D. Loss of bowel and bladder control
A.
A client with a spinal cord injury at levels C5
to C6 has quadriplegia with gross arm
movement and diaphragmatic breathing.
Injury levels C1 to C4 leads to quadriplegia
with total loss of respiratory function.
Paraplegia with intercostal muscle loss
occurs with injuries at T1 to L2. Injuries
below L2 cause paraplegia and loss of
bowel and bladder control.
A 30-year-old was admitted to the
progressive care unit with a C5 fracture
from a motorcycle accident. Which of the
following assessments would take priority?
A. Bladder distension
B. Neurological deficit
C. Pulse ox readings
D. The client's feelings about the injury
C. Pulse ox readings
After a spinal cord injury, ascending cord
edema may cause a higher level of injury.
The diaphragm is innervated at the level of
C4, so assessment of adequate
oxygenation and ventilation is necessary.
Although the other options would be
necessary at a later time, observation for
respiratory failure is the priority.
A client is admitted with a spinal cord injury
at the level of T12. He has limited
movement of his upper extremities. Which
of the following medications would be used
to control edema of the spinal cord?
A. Acetazolamide (Diamox)
B. Furosemide (Lasix)
C. Methylprednisolone (Solu-Medrol)
D. Sodium bicarbonate
C. Solu-Medrol
High doses of Solu-Medrol are used within
24 hours of spinal injury to reduce cord
swelling and limit neurological deficit. The
other drugs aren't indicated in this
circumstance
The nurse is caring for a client with a T5
complete spinal cord injury. Upon
assessment, the nurse notes flushed skin,
diaphoresis above the T5, and a blood
pressure of 162/96. The client reports a
severe, pounding headache. Which of the
following nursing interventions would be
appropriate for this client? Select all that
apply.
A. Elevate the HOB to 90 degrees
B. Loosen constrictive clothing
C. Use a fan to reduce diaphoresis
D. Assess for bladder distention and bowel
impaction
E. Administer antihypertensive medication
A, B, D, E
The client has signs and symptoms of
autonomic dysreflexia. The potentially life-
threatening condition is caused by an
uninhibited response from the sympathetic
nervous system resulting from a lack of
control over the autonomic nervous system.
The nurse should immediately elevate the
HOB to 90 degrees and place extremities
dependently to decrease venous return to
the heart and increase venous return from
the brain. Because tactile stimuli can trigger
autonomic dysreflexia, any constrictive
clothing should be loosened. The nurse
should also assess for distended bladder
and bowel impaction, which may trigger
autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the
most life-threatening complication of
autonomic dysreflexia because it can cause
stroke, MI, or seizures. If removing the
triggering event doesn't reduce the client's
blood pressure, IV antihypertensives should
be administered. A fan shouldn't be used
because cold drafts may trigger autonomic
dysreflexia.
The nurse is caring for a client who suffered
a spinal cord injury 48 hours ago. The nurse
monitors for GI complications by assessing
for:
A. A flattened abdomen
B. Hematest positive nasogastric tube
drainage
C. Hyperactive bowel sounds
D. A history of diarrhea
B. Hematest positive NG drainage
After spinal cord injury, the client can
develop paralytic ileus, which is
characterized by the absence of bowel
sounds and abdominal distention.
Development of a stress ulcer can be
detected by hematest positive NG tube
aspirate or stool. A history of diarrhea is
irrelevant.
A 40-year-old paraplegic must perform
intermittent catheterization of the bladder.
Which of the following instructions should
be given?
A. "Clean the meatus from back to front."
B. "Measure the quantity of urine."
C. "Gently rotate the catheter during
removal."
D. "Clean the meatus with soap and water."
D. Soap and Water
Intermittent catheterization may be
performed chronically with clean technique,
using soap and water to clean the urinary
meatus. The meatus is always cleaned from
front to back in a woman, or in expanding
circles working outward from the meatus in
a man. It isn't necessary to measure the
urine. The catheter doesn't need to be
rotated during removal.
While in the ER, a client with C8 tetraplegia
develops a blood pressure of 80/40, pulse
48, and RR of 18. The nurse suspects
which of the following conditions?
A. Autonomic dysreflexia
B. Hemorrhagic shock
C. Neurogenic shock
D. Pulmonary embolism
C. Neurogenic shock
Symptoms of neurogenic shock include
hypotension, bradycardia, and warm, dry
skin due to the loss of adrenergic
stimulation below the level of the lesion.
Hypertension, bradycardia, flushing, and
sweating of the skin are seen with
autonomic dysreflexia. Hemorrhagic shock
presents with anxiety, tachycardia, and
hypotension; this wouldn't be suspected
without an injury. Pulmonary embolism
presents with chest pain, hypotension,
hypoxemia, tachycardia, and hemoptysis;
this may be a later complication of spinal
cord injury due to immobility.
The nurse is planning care for the client in
spinal shock. Which of the following actions
would be least helpful in minimizing the
effects of vasodilation below the level of the
injury?
A. Monitoring vital signs before and during
position changes
B. Using vasopressor medications as
prescribed
C. Moving the client quickly as one unit
D. Applying Teds or compression stockings
C. Moving the client quickly as one unit
Reflex vasodilation below the level of the
spinal cord injury places the client at risk for
orthostatic hypotension, which may be
profound. Measures to minimize this include
measuring vital signs before and during
position changes, use of a tilt-table with
early mobilization, and changing the client's
position slowly. Venous pooling can be
reduced by using Teds (compression
stockings) or pneumatic boots. Vasopressor
medications are administered per protocol.
A 22-year-old client with quadriplegia is
apprehensive and flushed, with a blood
pressure of 210/100 and a heart rate of 50
bpm. Which of the following nursing
interventions should be done first?
A. Place the client flat in bed
B. Assess patency of the indwelling urinary
catheter
C. Give one SL nitroglycerin tablet
D. Raise the head of the bed immediately to
90 degrees
D. Raise HOB 90 degrees
Anxiety, flushing above the level of the
lesion, piloerection, hypertension, and
bradycardia are symptoms of autonomic
dysreflexia, typically caused by such
noxious stimuli such as a full bladder, fecal
impaction, or decubitus ulcer. Putting the
client flat will cause the blood pressure to
increase even more. The indwelling urinary
catheter should be assessed immediately
after the HOB is raised. Nitroglycerin is
given to reduce chest pain and reduce
preload; it isn't used for hypertension or
dysreflexia.
A client with a cervical spine injury has
Gardner-Wells tongs inserted for which of
the following reasons?
A. To hasten wound healing
B. To immobilize the cervical spine
C. To prevent autonomic dysreflexia
D. To hold bony fragments of the skull
together
B. Immobilize cervical spine
Gardner-Wells, Vinke, and Crutchfield tongs
immobilize the spine until surgical
stabilization is accomplished
The nurse is evaluating neurological signs
of the male client in spinal shock following
spinal cord injury. Which of the following
observations by the nurse indicates that
spinal shock persists?
A. Positive reflexes
B. Hyperreflexia
C. Inability to elicit a Babinski's reflex
D. Reflex emptying of the bladder
C. Babinski's reflex
Resolution of spinal shock is occurring
when there is a return of reflexes (especially
flexors to noxious cutaneous stimuli), a
state of hyperreflexia rather than flaccidity,
reflex emptying of the bladder, and a
positive Babinski's reflex.