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


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?

  1. Superficial
  2. Partial-thickness superficial
  3. Partial-thickness deep
  4. 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?

  1. Superficial
  2. Partial-thickness superficial
  3. Partial-thickness deep
  4. 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?

  1. The medication will be effective more quickly than if given intramuscularly.
  2. It is less likely to interfere with the client’s breathing and oxygenation.
  3. The danger of an overdose during fluid remobilization is reduced.
  4. The client delayed gastric emptying.







4.Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

  1. Vitamin A
  2. Vitamin B
  3. Vitamin C
  4. Vitamin D







5. Which client factors should alert the nurse to potential increased complications with a burn injury?

  1. The client is a 26-year-old male.
  2. The client has had a burn injury in the past.
  3. The burned areas include the hands and perineum.
  4. The burn took place in an open field and ignited the client’s clothing.







6. The burned client is ordered to receive intravenous imetidine, 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?

  1. “To increase the urine output and prevent kidney damage.”
  2. “To stimulate intestinal movement and prevent abdominal bloating.”
  3. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
  4. “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?

  1. Immediately following the injury
  2. During the fluid shift
  3. During fluid remobilization
  4. 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?

  1. Pulse oximetry reading of 80%
  2. Expiratory stridor and nasal flaring
  3. Cherry red color to the mucous membranes
  4. Presence of carbonaceous particles in the sputum







9. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

  1. The burn is full thickness rather than partial thickness.
  2. The client is unable to fully pronate and supinate the extremity.
  3. Capillary refill is slow in the digits and the distal pulse is absent.
  4. 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?

  1. Total protein
  2. Tissue type antigens
  3. Prostate specific antigen
  4. 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?

  1. Colloids
  2. Crystalloids
  3. Fresh-frozen plasma
  4. 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?

  1. Administer oxygen.
  2. Loosen the dressing.
  3. Notify the emergency team.
  4. 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?

  1. Raise the head of the bed.
  2. Notify the emergency team.
  3. Loosen the dressings on the chest.
  4. 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?

  1. Notify the emergency team.
  2. Document the finding as the only action.
  3. Ask the client if anyone in her family has diabetes mellitus.
  4. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.







15. On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?

  1. Fluid shift
  2. Intense pain
  3. Hemorrhage
  4. 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?

  1. Reposition the client onto the right side.
  2. Document the finding as the only action.
  3. Notify the emergency team.
  4. Increase the IV flow rate







17.Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

  1. Increased urine output, decreased urine specific gravity
  2. Increased peripheral edema, decreased blood pressure
  3. Decreased peripheral pulses, slow capillary refill
  4. 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?

  1. Risk for Ineffective Breathing Pattern
  2. Decreased Tissue Perfusion
  3. Risk for Disuse Syndrome
  4. 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?

  1. Serum sodium elevated to 131 mmol/L (mEq/L)
  2. Serum potassium 7.5 mmol/L (mEq/L)
  3. Arterial pH is 7.32
  4. 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?

  1. Airway patency
  2. Heart rate and rhythm
  3. Orientation to time, place, and person
  4. Current range of motion in all extremities







21. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

  1. “Are you a smoker?”
  2. “When was your last chest x-ray?”
  3. “Have you ever had asthma or any other lung problem?”
  4. “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?

  1. The client is able to talk.
  2. The client is alert and oriented.
  3. The client’s oxygen saturation is 97%.
  4. The client’s chest movements are uninhibited







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

  1. The client is able to talk.
  2. The client is alert and oriented.
  3. The client’s oxygen saturation is 97%.
  4. 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?

  1. “When fluid remobilization has started.”
  2. “When the burn wounds are closed.”
  3. “When IV fluids are discontinued.”
  4. “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?

  1. Seasonal asthma
  2. Hepatitis B 10 years ago
  3. Myocardial infarction 1 year ago
  4. 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?

  1. Assess level of consciousness and pupillary reactions.
  2. Ask the client at what time food or liquid was last consumed
  3. Auscultate breath sounds over the trachea and mainstem bronchi
  4. 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?

  1. Handwashing on entering the client’s room
  2. Encouraging the client to cough and deep breathe
  3. Administering the prescribed tetanus toxoid vaccine
  4. 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?

  1. The total white blood cell count is 9000/mm3.
  2. The lymphocytes outnumber the basophils.
  3. The “bands” outnumber the “segs.”
  4. 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?

  1. Place a towel roll under the client’s neck or shoulder.
  2. Keep the client in a supine position without the use of pillows.
  3. Have the client turn the head from side to side 90 degrees every hour while awake.
  4. 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 maintain to retain maximum function of this joint?

  1. Hip maintained in 30-degree flexion, no knee flexion
  2. Hip flexed 90 degrees and knee flexed 90 degrees
  3. Hip, knee, and ankle all at maximum flexion
  4. 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?

  1. Increased wound pain 30 to 40 minutes after drug application
  2. Presence of small, pale pink bumps in the wound beds
  3. Decreased white blood cell count
  4. Increased serum creatinine leve








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?

  1. Nothing, because the findings are normal for clients during the acute phase of recovery.
  2. Increase the temperature in the room and increase the IV infusion rate.
  3. Assess the client’s airway and oxygen saturation.
  4. 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?

  1. Changing gloves between wound care on different parts of the client’s body.
  2. Avoiding sharing equipment such as blood pressure cuffs between clients.
  3. Using the closed method of burn wound management.
  4. Using proper and consistent handwashing







34. When should ambulation be initiated in the client who has sustained a major burn?

  1. When all full-thickness areas have been closed with skin grafts
  2. When the client’s temperature has remained normal for 24 hours
  3. As soon as possible after wound debridement is complete
  4. 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?
  1. “For the first few days after surgery, the donor sites will be painful.”
  2. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
  3. “I will have some scarring in the area when the skin is removed for grafting.”
  4. “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?

  1. “I will never be fully recovered from the burn.”
  2. “I am considered fully recovered when all the wounds are closed.”
  3. “I will be fully recovered when I am able to perform all the activities I did before my injury.”
  4. “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?

  1. “After this treatment, my ears will not stick out.”
  2. “The mask will help protect my skin from sun damage.”
  3. “Using this mask will prevent scars from being permanent.”
  4. “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?

  1. Acute Pain
  2. Impaired Adjustment
  3. Deficient Diversional Activity
  4. Imbalanced Nutrition: Less than Body Requirements







39. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:

  1. Total volume of circulating whole blood
  2. Total volume of intravascular plasma
  3. Permeability of capillary walls
  4. 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:

  1. Maintain room humidity below 40%
  2. Place top sheet on the client
  3. Limit the occurrence of drafts
  4. Keep room temperature at 80 degrees





ESIC Staff Nurse Exam Model Question Answers 2019



















































































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