ATI MED SURG – Caring for Patients with Burns – Study Guide Latest Updated With Complete Solutions

ATI MED SURG – Caring for Patients with Burns – Study Guide Latest Updated With Complete Solutions
1) The nurse is using the Rule of Nines to calculate the extent of a client’s burn injury. The client has burns on the anterior and posterior surface of the right arm, the anterior surface of the left lower extremity, and anterior and posterior surfaces of the right lower extremity. The nurse should document the percent of body surface burned is
A. 36%.
B. 45%.
C. 18%.
D. 27%.

2) The nurse is caring for a male client who sustained full-thickness burns on the back and the posterior legs six hours ago. Which of the following laboratory values would be an initial expected finding
A. A hematocrit (Hct) level of 40%. B. A serum potassium level of 5.6.
C. A white blood cell (WBC) count of 30,000 mm3.
D. An elevated carboxyhemoglobin (COHb) level.

3) The nurse working in the ED is caring for a client who sustained burns to both feet. It would be appropriate for the nurse to document that the client has sustained a superficial partial-thickness burn if the nurse observes the presence of
A. yellow skin with severe edema, the absence of blisters, and hard and inelastic eschar.
B. dark pink skin that blanches slowly and with no pain.
C. white and red skin that is dry, and no presence of blisters.
D. red skin that is moist with blisters that are leaking serous fluid.

4) The nurse working in the ED is caring for a client who was rescued from a house fire. It would be necessary for the nurse to immediately notify the ED health care provider if the client
A. has severe edema and brown, discolored skin on the arms.
B. is reporting pain rated ‘9’ on a scale of ‘0’ (no pain) to ‘10’ (severe pain).
C. is unable to state the day of the week and the time.
D. has singed nasal hairs and complains of difficulty swallowing.

5) The nurse is caring for a client who sustained an electrical injury and was brought to the ED by a neighbor. It would be appropriate for the nurse to initially assess the client’s
A. kidney function, and obtain a urinalysis.
B. entrance and exit sites, and obtain cardiac enzymes.
C. allergy to medications, and obtain a prescription for a broad spectrum antibiotic.
D. heart rate and rhythm, and obtain an electrocardiogram (EKG).

6) The nurse is caring for a client who was admitted to the ED with deep full-thickness burns to the full anterior torso chest. The client weighs 198 lbs. What is the amount of fluid replacement that will be required in the first eight hours, using 4 mL/kg when calculating the fluid replacement?
A. 9,720 mL.
B. 3,240 mL.
C. 6,480 mL.
D. 12,960 mL.

7) The nurse working in the ED is admitting a client who was in a house fire and sustained deep partial full-thickness and full-thickness burns to the chest, back, and arms. It would be a priority for the nurse to notify the ED health care provider if the nurse observes that the client has
A. vesicular breath sounds in the peripheral lung fields. B. a cherry-red color to the face.
C. a documented allergy to codeine.
D. a burned total body surface area (TBSA) of 40%.

8) The nurse has attended an in-service on the administration of fluid replacement therapy to clients who have sustained burns. Which of the following statements by the nurse would indicate a correct understanding of the teaching?
A. “One-half of the required fluid volume should be administered in the first eight hours from the time of arrival.”
B. “IV fluids should be titrated so that the client has an hourly urine output of 1 mL/kg.”
C. “Fluid boluses should be used to help increase the client’s capillary pressure.”
D. “Crystalloids should be should be administered for the first 24 hours.”

9) The nurse working in the ED is caring for a client with a 65% TBSA burn injury. After assessing for patency of the client’s airway, which of the following prescribed interventions should the nurse implement first?
A. Initiate intravenous fluids.
B. Insert an indwelling urethral catheter.
C. Administer a tetanus toxoid in the deltoid muscle.
D. Perform a gastrointestinal assessment.

10) The nurse working on the burn step-down unit has become aware of the following client situations. The nurse should initially follow up with the client who has
A. refused to attend physical therapy for the second day in a row.
B. only been eating 2,500 calories per day for the last four days.
C. developed redness and edema at the wound edges extending to the non-burned skin.
D. an allergy to penicillin and has been prescribed the topical cream, gentamicin sulfate.

11) The nurse is admitting a client who has sustained burns on the chest, has singed nasal hairs, and appears confused. Which action should the nurse take first?
A. Assess the client’s neurological status.
B. Connect the client to a telemetry monitor.
C. Elevate the head of the client’s bed to at least 45 degrees.
D. Determine if the client has a patent IV.

12) The nurse is caring for a client who weighs 182 lbs and sustained burns over 55% of the TBSA. It would require follow up with the primary health care provider if the client’s urine output is noted to be
A. 0.6 mL/kg/hr.
B. 1,800 mL over 24 hours.
C. 800 mL over eight hours.
D. 0.25 mL/kg/hr.




13) What is the best method to prevent autocontamination for a client with burns?

A. Change gloves when handling wounds on different areas of the body.
B. Ensure that the client is in isolation therapy.
C. Restrict visitors.
D. Watch for early signs of infection.

14) When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors?
A. “Every bedroom should have a separate smoke detector.”
B. “Every room in the house should have a smoke detector.”
C. “If you have a smoke detector, you don’t need a carbon monoxide detector.”
D. “The kitchen and the bedrooms are the only rooms that need smoke detectors.”

15) During the rehabilitation phase, the physical healing focuses primarily on wound healing. The burn nurse includes which the following in patient education to assist the patient and family for their return to the community?

A. The immune system heals along with the skin and future risk of infection stabilizes.
B. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.
C. Extensive burn injury decreases the risk for developing bone density changes.
D. Thermoregulation disturbances may result in an inability to adjust to changes in environment temperatures.