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RT1. The newly admitted client has burns on both legs. The burned
areas appear white and leather-like. No blisters or bleeding are
present, and the client states that he or she has little pain. How
should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
2. The newly admitted client has a large burned area on the right
arm. The burned area appears red, has blisters, and is very painful.
How should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
A. Vitamin A
B. Vitamin B
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C. Vitamin C
D. Vitamin D
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A. Total protein
B. Tissue type antigens
C. Prostate-specific antigen
D. Hemoglobin S electrophoresis
11. Which type of fluid should the nurse expect to prepare and
administer as fluid resuscitation during the emergent phase of burn
recovery?
A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells
12. The client with a dressing covering the neck is experiencing some
respiratory difficulty. What is the nurse’s best first action?
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A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
13. The client who experienced an inhalation injury 6 hours ago has
been wheezing. When the client is assessed, wheezes are no longer
heard. What is the nurse’s best action?
A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning
16. Twelve hours after the client was initially burned, bowel sounds
are absent in all four abdominal quadrants. What is the nurse’s best
action?
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30. The client has severe burns around the right hip. Which position
is most important to be emphasized by the nurse that the client
maintains to retain maximum function of this joint?
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32. The client, who is 2 weeks postburn with a 40% deep partial-
thickness injury, still has open wounds. On taking the morning vital
signs, the client is found to have a below-normal temperature, is
hypotensive, and has diarrhea. What is the nurse’s best action?
A. Nothing, because the findings are normal for clients during the acute
phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.
A. When all full-thickness areas have been closed with skin grafts
B. When the client’s temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift
35. What statement by the client indicates the need for further
discussion regarding the outcome of skin grafting (allografting)
procedures?
A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
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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.”
A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements
39. Nurse Faith should recognize that fluid shift in an client with burn
injuryresults from increase in the:
:
Here are the answers and rationale for this exam. Counter check your
answers to those below and tell us your scores. If you have any disputes or
need more clarification to a certain question, please direct them to the
comments section.
Option D: The characteristics of the wound meet the criteria for a
full-thickness injury (color that is black, brown, yellow, white or red;
no blisters; pain minimal; outer layer firm and inelastic).
Option B: The characteristics of the wound meet the criteria for a
superficial partial-thickness injury (color that is pink or red; blisters;
pain present and high).
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4. Answer: D. Vitamin D
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9. Answer: C. Capillary refill is slow in the digits and the distal pulse
is absent.
Option D: Sickle cell disease and sickle cell trait are more common
among African Americans. Although clients with sickle cell disease
usually know their status, the client with sickle cell trait may not.
The fluid, circulatory, and respiratory alterations that occur in the
emergent phase of a burn injury could result in decreased tissue
perfusion that is sufficient to cause sickling of cells, even in a person
who only has the trait. Determining the client’s sickle cell status by
checking the percentage of hemoglobin S is essential for any African
American client who has a burn injury.
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