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Medical-Surgical Nursing Exam 13: Burns (40 Items)

1. Answer: A 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 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 fullthickness 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 potassium excreted 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 handwashing can prevent crosscontamination. 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 kidney function 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 preburn 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 lifechanging 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. Answer: C A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas. Navigation 1. View Questions 2. View Answers & Rationale