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

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 client’s 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 client’s clothing.

6. 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.”

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 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.

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. 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 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.

15. On admission to the emergency department the burned

client’s bloodpressure 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 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.

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 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%

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 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?”

22. 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

23. 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

24. 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.”

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 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.

27. Which intervention is most important for the nurse to use to

prevent infectionby 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

28. 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.

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 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.

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?

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 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.

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 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.

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 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’.”
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 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.”

37. 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.”

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 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

>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. Answer: D. Full thickness

 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).

2. Answer: B. Partial-thickness superficial

 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).

3. Answer: C. The danger of an overdose during fluid remobilization

is reduced.
  Option 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. Vitamin D

 Option 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. The burned areas include the hands and perineum.

 Option 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. “To decrease hydrochloric acid production in

the stomach and prevent ulcers.”

 Option 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. During fluid remobilization

 Option 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. Cherry red color to the mucous membranes

  Option 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. Capillary refill is slow in the digits and the distal pulse
is absent.

 Option 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. Hemoglobin S electrophoresis

 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.

11. Answer: B. Crystalloids

 Option B: Although not universally true, most fluid resuscitation for

burn injuries starts with crystalloid solutions, such as normal
saline and Ringer’s lactate.
 Option D: The burn client rarely requires blood during the
emergent phase unless the burn is complicated by another injury
that involved hemorrhage.
  Options A and C: 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. Loosen the dressing.

 Option B: 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.

13. Answer: B. Notify the emergency team.

 Option 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. Document the finding as the only action.

 Option 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. Fluid shift

 Option 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. Document the finding as the only action.

 Option 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.
 Options A, C, and D: No currently accepted intervention changes
this response, and it is not the highest priority of care at this time.

17. Answer: A. Increased urine output, decreased urine specific

gravity

 Option 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. Risk for Disuse Syndrome

 Option 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. Serum potassium 7.5 mmol/L (mEq/L)

 Option 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. Heart rate and rhythm

  Option 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. “In what exact place or space were you when you
were burned?”

 Option 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. The client’s oxygen saturation is 97%.

 Option 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. The client’s oxygen saturation is 97%.

 Option 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. “When the burn wounds are closed.”

 Option 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. Myocardial infarction 1 year ago

 Option 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. Auscultate breath sounds over the trachea and

mainstem bronchi.

 Option C: 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.

27. Answer: A. Handwashing on entering the client’s room

 Option 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. The “bands” outnumber the “segs.”

 Option 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 client’s
immune system cannot keep pace with the infectious process.

29. Answer: C. Have the client turn the head from side to side 90
degrees every hour while awake.
  Option 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. Hip at zero flexion with leg flat

 Option 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. Increased serum creatinine level

 Option 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 kidney function monitored.

32. Answer: D. Notify the burn emergency team.

 Option D: These findings are associated with systemic gram-

negative infection and sepsis. This is a medical emergency and
requires prompt attention.

33. Answer: A. Changing gloves between wound care on different

parts of the client’s body.

 Option A: 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.

34. Answer: D. As soon as possible after resolution of the fluid shift

 Option 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. “Because the graft is my own skin, there is no chance

it won’t ‘take’.”

 Option 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. “I will be fully recovered when I achieve the highest

possible level of functioning that I can.”

 Option 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. “My facial scars should be less severe with the use of
this mask.”

 Option 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. Impaired Adjustment

 Option 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.
 Option A: By the rehabilitation phase, acute pain from the injury or
its treatment is no longer a problem.

39. Answer: C. Permeability of capillary walls

 Option 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. Answer: C. Limit the occurrence of drafts

 Option C: A Client with burns is very sensitive to temperature

changes because heat is loss in the burn areas.