1.

The clients serum potassium level is elevated in acute renal failure, and the nurse
administers sodium polystyrene sulfonate (Kayexalate). This drug acts to
a. Increase potassium excretion from the colon.
b. Release hydrogen ions for sodium ions
c. Increase calcium absorption for potassium ions in the colon.

ANSWER

A. Increased potassium excretion from the colon

Kayexalate cation exchange resin, excrete potassium through GI tract. In the colon, the
sodium of the resin is replaced by the potassium.

2. In the oliguric phase of acute renal failure, the nurse should anticipate the development
of which of the following complications?
a. Pulmonary edema
b. Metabolic alkalosis
c. Hypotension
d. Hypokalemia

ANSWER

A. PULMONARY EDEMA.

Pulmonary edema can develop during the oliguric phase of acute renal failure because of
decreased urinary output and fluid retention.

3. A client developed shock after a severe myocardial infarction and has now developed
renal failure. The clients family asks the nurse why the client has developed acute renal
failure. The nurse should base the response on the knowledge that there was
a. A decrease in the blood flow through kidneys.
b. An obstruction of urine flow from the kidneys.
c. A blood clot formed in the kidneys.
d. Structural damage to the kidney resulting in acute tubular necrosis.

ANSWER

A. A decrease in the blood flow through the kidneys.

Pre-renal occur outside of the kidney includes poor perfusion and decrease in
circulating volume resulting from trauma, septic shock, impaired cardiac function and
dehydration.

4. Which of the following abnormal blood values would not be improved by dialysis
treatment?
a. Elevated serum creatinine
b. Hyperkalemia
c. Decreased hemoglobin
d. Hypernatremia
ANSWER

C. Decreased Hemoglobin

Erythropoeitin stimulation is absent in clients with ARF and is corrected only with
weekly administration of the medication via subcutaneous route.

5. What is the primary disadvantage of using peritoneal dialysis for long term
management of chronic renal failure?
a. The danger of hemorrhage is high
b. It cannot correct severe imbalances.
c. It is a time-consuming method of treatment.
d. The risk of contracting hepatitis is high.

ANSWER

C. It is a time-consuming method of treatment.

Dwelling time usually consumes around 8-16-24 hours and might impede the client to do
activities of daily living.

1. 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

Answer: 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).

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

3. 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 clients breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.
4. 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

5. 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 clients clothing.

6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking

agent, during the emergent phase. When the clients family asks why this drug is being given,
what is the nurses 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.

7. 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

8. 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
9. 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.

10. 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

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 nurses best first action?

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 nurses 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.

14. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL.
What is the nurses 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 Ringers lactate.

15. On admission to the emergency department the burned clients 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

16. Twelve hours after the client was initially burned, bowel sounds are absent in all four
abdominal quadrants. What is the nurses 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.

17. 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

18. 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

19. All of the following laboratory test results on a burned clients 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%

20. 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

21. In assessing the clients 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?

22. Which information obtained by assessment ensures that the clients respiratory efforts are
currently adequate?

A. The client is able to talk.

B. The client is alert and oriented.
C. The clients oxygen saturation is 97%.
D. The clients chest movements are uninhibited

23. Which information obtained by assessment ensures that the clients respiratory efforts are
currently adequate?

A. The client is able to talk.

B. The client is alert and oriented.
C. The clients oxygen saturation is 97%.
D. The clients chest movements are uninhibited

24. The burned clients family ask at what point the client will no longer be at increased risk
for infection. What is the nurses 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.
25. 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

26. The burned client on admission is drooling and having difficulty swallowing. What is the
nurses 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.

27. 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 clients 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

28. In reviewing the burned clients 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.

29. 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 clients 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-Fowlers position and actively raise the arms above the head every hour
while awake.
30. 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

31. 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

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 nurses 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 clients airway and oxygen saturation.
D. Notify the burn emergency team.

33. 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 clients 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.

34. 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 clients 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 wont 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.

36. 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.

37. 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.

38. 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

39. Nurse Faith should recognize that fluid shift in an client with burn injuryresults 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

40. Louie, with burns over 35% of the body, complains of chilling. In promoting the clients
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
Answer: C
A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.

Answers & Rationale

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.

1.

2. Answer: B

The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that
is pink or red; blisters; pain present and high).

3. Answer: C

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.

4. Answer: 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.

5. Answer: C

Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to
ensure the best functional outcome.
6. Answer: C

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.

7. Answer: C

Hypokalemia is most likely to occur during the fluid remobilization period as a result of
dilution, potassium movement back into the cells, and increased potassiumexcreted into
the urine with the greatly increased urine output.

8. Answer: C

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.

9. Answer: C

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.

10. Answer: 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 clients sickle cell status by checking the percentage of hemoglobin S is
essential for any African American client who has a burn injury.

11. Answer: B

Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid
solutions, such as normal saline and Ringers 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.
12. Answer: B

Respiratory difficulty can arise from external pressure. The first action in this situation would be to
loosen the dressing and then reassess the clients respiratory status.

13. Answer: B

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.

14. Answer: B

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.

15. Answer: A

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.

16. Answer: B 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.

17. Answer: A

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.

18. Answer: C

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.

19. Answer: B
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.

20. Answer: B

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.

21. Answer: D

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.

22. Answer: C

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.

23. Answer: C

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.

24. Answer: B

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.

25. Answer: C

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.

26. Answer: C
Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede
pulmonary failure. The clients airway is in severe jeopardy and intubation is highly likely to be
needed shortly.

27. Answer: A

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.

28. Answer: C

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 clients immune system cannot keep pace with the infectious
process.

29. Answer: C

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.

30. Answer: D

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.

31. Answer: D

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 kidneyfunction monitored.

32. Answer: D

These findings are associated with systemic gram-negative infection and sepsis. This is a medical
emergency and requires prompt attention.

33. Answer: A
Autocontamination is the transfer of microorganisms from one area to another area of the same
clients 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 clients body can prevent autocontamination.

34. Answer: D

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.

35. Answer: B

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.

36. Answer: D

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.

37. Answer: D

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.

38. Answer: B

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.

39. Answer: C

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.
40.