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