TEST BANK MS I NURSING QUESTIONS AND ANSWERS GRADED A(100% APPROVED)2021/2022
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MLS 3113
Institution
MLS 3113
1. The optimal measurement of intravascular fluid status during the
immediate fluid resuscitation phase of burn treatment is:
a. blood urea nitrogen.
b
. daily weight.
c. hourly intake and urine output.
d
. serum potassium.
ANS: C
During initial fluid resuscitation, urine output helps guid...
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TEST BANK MS I NURSING QUESTIONS AND ANSWERS GRADED A(100%
APPROVED)2021/2022
1. The optimal measurement of intravascular fluid status during the
immediate fluid resuscitation phase of burn treatment is:
a. blood urea nitrogen.
b
. daily weight.
c. hourly intake and urine output.
d
. serum potassium.
ANS: C
During initial fluid resuscitation, urine output helps guide fluid
resuscitation needs. Measuring hourly intake and output is most
effective in determining the needs for additional fluid infusion than
is urine output alone. Blood urea nitrogen may be used to monitor
volume status, but it is affected by the hypermetabolic state seen
after burns, so it is not the optimal measure of intravascular fluid
status. Daily weight measures overall volume status, not just
intravascular volume. Serum potassium is released with tissue
damage and thus is not the optimum measure of intravascular fluid
status.
DIF: Cognitive Level: Comprehension REF: p. 636
OBJ: Discuss the primary and secondary survey assessments during
resuscitation and the acute phases of burn management. TOP: Nursing
Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. In patients with extensive burns, edema occurs in both burned
and unburned areas because of:
a. catecholamine-induced vasoconstriction.
b
. decreased glomerular filtration.
c. increased capillary permeability.
d
. loss of integument barrier.
ANS: C
Capillary permeability is altered in burns beyond the area of tissue
damage, resulting in significant shift of proteins, fluid, and
electrolytes resulting in edema (third spacing). Catecholamine-
induced vasoconstriction does not produce edema. Decreased
glomerular filtration may cause fluid retention, but it is not
responsible for the extensive edema seen after burn injury. Loss of
integument barrier does not cause edema.
,DIF: Cognitive Level: Comprehension REF: p. 626
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
3. Tissue damage from burn injury activates an inflammatory
response that increases the patients risk for:
a. acute kidney injury.
b
. acute respiratory distress syndrome.
c. infection.
d
. stress ulcers.
ANS: C
The loss of skin as the primary barrier against microorganisms and
activation of the inflammatory response cascades results in
immunosuppression, placing the patient at an increased risk of
infection. A systemic inflammatory response (SIRS) also increases
the risk of acute kidney injury in the presence of poor tissue
perfusion. Acute respiratory distress syndrome is also a potential
complication, but the risk of infection is greater because of the loss
of the skin barrier. Catecholamine release and gastrointestinal
ischemia are the causes of stress ulcers.
DIF: Cognitive Level: Comprehension REF: pp. 622-623
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a burn-injured patient who weighs 154
pounds, and the burn injury covers 50% of his body surface area.
The nurse calculates the fluid needs for the first 24 hours after a
burn injury using a standard fluid resuscitation formula of 4 mL/kg/%
burn of intravenous (IV) fluid for the first 24 hours. The nurse plans
to administer what amount of fluid in the first 24 hours?
a. 2800 mL
b
. 7000 mL
c. 14 L
d
. 28 L
ANS: C
154 pounds/2.2 = 70 kg
4 70 kg 50 = 14,000 mL, or 14 liters.
DIF: Cognitive Level: Application REF: p. 636 | Box 20-1
,OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
5. The nurse is caring for a patient who has circumferential full-
thickness burns of his forearm? A priority in the plan of care is :
a. Keeping the extremity in a dependent position
b
. Active and passive range of motion every hour.
c. Preparing for an escharotomy as a prophylactic measure
d
. Splinting the forearm
ANS: B
Special attention is given to circumferential (completely surrounding
a body part) full thickness
burns of the extremities. Pressure from bands of eschar or from
edema that develops as resuscitation proceeds may impair blood
flow to underlying and distal tissue. Therefore, extremities are
elevated to reduce edema. Active or passive range-of-motion (ROM)
exercises are performed every hour for 5 minutes to increase
venous return and to minimize edema. Peripheral pulses are
assessed every hour, especially in circumferential burns of the
extremities, to confirm adequate circulation. If signs and symptoms
of compartment syndrome are present on serial examination,
preparation is made for an escharotomy to relieve pressure and to
restore circulation.
DIF: Cognitive Level: Application REF: p. 638
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The patient asks the nurse if the placement of the autograft over
his full-thickness burn will be the only surgical intervention needed
to close his wound. The nurses best response would be:
Unfortunately, an autograft skin is a temporary graft and a
a. second surgery will be needed to close the wound.
b An autograft is a biological dressing that will eventually be
. replaced by your body generating new tissue.
Yes, an autograft will transfer your own skin from one area of
c. your body to cover the burn wound.
d Unfortunately, autografts frequently do not adhere well to burn
. wounds and a xenograft will be necessary to close the wound.
, ANS: C
The autograft is the only permanent method of grafting and it uses
the patients own tissue to cover the burn wound. Autografting is
permanent and does not require a second surgery unless the graft
fails. A biological or biosynthetic graft or dressing is a temporary
wound covering. A xenograft is from an animal, usually pig skin and
is a temporary graft.
DIF: Cognitive Level: Application REF: p. 647
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. A patient admitted with severe burns to his face and hands is
showing signs of extreme agitation. The nurse should explore the
mechanism of burn injury possibly related to:
a. excessive alcohol use.
b
. methamphetamine use.
c. posttraumatic stress disorder.
d
. subacute delirium.
ANS: B
A vague or inconsistent injury history, burns to the face and hands,
and signs of agitation or substance withdrawal should alert the
nurse to a potential methamphetamine-related injury.
DIF: Cognitive Level: Application REF: p. 616 OBJ: Compare types of burns.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse is caring for patient who has been struck by lightning.
Because of the nature of the injury, the nurse assesses the patient
for which of the following?
a. Central nervous system deficits
b
. Contractures
c. Infection
d
. Stress ulcers
ANS: A
Lightning injury frequently causes cardiopulmonary arrest. However,
of those patients who survive, 70% will have transient central
nervous system deficits. Contractures, infection, and stress ulcer
risks are no greater than with other causes of burn injury.
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