MEDSURG EXAM 2 QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLUTION THAT COVERS
2024/2025 BEST RATED TO SCORE A+
A client is brought to the emergency department from the site of a chemical fire, where the
client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the
right arm. On inspection, the skin appears charred. Based on these assessment findings,
what is the depth of the burn on the client's arm?
A. Superficial partial thickness
B. Deep partial thickness
C. Full partial thickness
D. Full thickness - CORRECT ANSWERS ANS: D
Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and,
in some cases, underlying tissue as well. Wound color ranges widely from white to red,
brown, or black. The burned area is painless because the nerve fibers are destroyed. The
wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also
be present. Superficial partial-thickness burns involve the epidermis and possibly a portion
of the dermis; the client will experience pain that is soothed by cooling. Deep partial-
thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the
client will report pain and sensitivity to cold air. Full partial thickness is not a depth of burn.
The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional
support, and prevention of complications such as infection. Based on these care priorities,
the client is in what phase of burn care?
A. Emergent
B. Immediate resuscitative
C. Acute
D. Rehabilitation - CORRECT ANSWERS ANS: C
Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative
phase and begins 48 to 72 hours after the burn injury. During this phase, attention is
directed toward continued assessment and maintenance of respiratory and circulatory
status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention,
burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing,
dressing changes, wound débridement, and wound grafting), pain management, and
nutritional support are priorities at this stage. Priorities during the emergent or immediate
resuscitative phase include first aid, prevention of shock and respiratory distress, detection
and treatment of concomitant injuries, and initial wound assessment and care. The priorities
,MEDSURG EXAM 2 QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLUTION THAT COVERS
2024/2025 BEST RATED TO SCORE A+
during the rehabilitation phase include prevention of scars and contractures, rehabilitation,
functional and cosmetic reconstruction, and psychosocial counseling.
A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial
blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the
results to indicate what findings?
A. Hyperkalemia, hyponatremia, elevated hematocrit
B. Hypokalemia, hypernatremia, decreased hematocrit
C. Hyperkalemia, hypernatremia, decreased hematocrit
D. Hypokalemia, hyponatremia, elevated hematocrit - CORRECT ANSWERS ANS: A
Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury
include hyperkalemia related to the release of potassium into the extracellular fluid,
hyponatremia from large amounts of sodium lost in trapped edema fluid, and
hemoconcentration that leads to an increased hematocrit.
A client has experienced an electrical burn and has developed thick eschar over the burn
site. Which of the following topical antibacterial agents will the nurse expect the health care
provider to order for the wound?
A. Silver sulfadiazine1% (Silvadene) water-soluble cream
B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream
C. Silver nitrate 0.5% aqueous solution
D. Acticoat - CORRECT ANSWERS ANS: B
Rationale: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there
is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a
type of silver dressing.
An occupational health nurse is called to the floor of a factory where a worker has sustained
a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The
next step is to "cool the burn." How should the nurse cool the burn?
A. Apply ice to the site of the burn for 5 to 10 minutes.
B. Wrap the client's affected extremity in ice until help arrives.
C. Apply an oil-based substance to the burned area until help arrives.
,MEDSURG EXAM 2 QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLUTION THAT COVERS
2024/2025 BEST RATED TO SCORE A+
D. Wrap cool towels around the affected extremity intermittently. - CORRECT ANSWERS
ANS: D
Rationale: Once the burn has been sustained, the application of cool water is the best first-
aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives
immediate and striking relief from pain, and limits local tissue edema and damage. However,
never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks
or dressings for longer than several minutes; such procedures may worsen the tissue
damage and lead to hypothermia in people with large burns. Oils are contraindicated.
An emergency department nurse has just admitted a client with a burn. What characteristic
of the burn will primarily determine whether the client experiences a systemic response to
this injury?
A. The length of time since the burn
B. The location of burned skin surfaces
C. The source of the burn
D. The total body surface area(TBSA) affected by the burn - CORRECT ANSWERS ANS: D
Rationale: Systemic effects are a result of several variables. However, TBSA and wound
severity are considered the major factors that affect the presence or absence of systemic
effects.
A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the
following classifications should the nurse use to document this burn?
A. Superficial thickness
B. Superficial partial thickness
C. Deep partial thickness
D. Full thickness - CORRECT ANSWERS ANS: A
The nurse should recognize the cues from the clients daya collection and document a
sunburn as a superficial thickness burn. Superficial burns damage the epidermis
A nurse is caring for a client who has sustained burns over 35% of total body surface area.
The client's voice has become hoarse, a brassy cough has developed, and the client is
, MEDSURG EXAM 2 QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLUTION THAT COVERS
2024/2025 BEST RATED TO SCORE A+
drooling. The murse should identify these findings as indications that the client has which of
the following?
A. Pulmonary Edema
B. Bacterial pneumonia
C. Inhalation injury
D. Carbon monoxide poisoning - CORRECT ANSWERS ANS: C
The nurse should identify wheezing and hoarseness indicate inhalation injury with
impending loss of the airway
A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns
ovber 40% of the body 24hr ago. which of the following findings are common during this
phase? (select all that apply)
A. hypoglycemia
B. decreased blood urea nitrogen
c. hyperkalemia
d. hyponatremia
e. decreased hematocrit - CORRECT ANSWERS ANS: C, D, E
C: the nurse should expect hyperkalemia which occurs during the inital phase following a
bnurn as a result of leakage of fluid from the intracellular space.
D: hyponatremia occurs during the initial phase of a burn as a result in sodium retention in
the interstitial space. The nurse should expect glucose to be elevated due to the stress
response and the client would demonstrate hyperglycemia
E: the client's BUN is elevated due to fluid loss from shift of fluid from the intravascular to
interstitial spaces. The Hct increases during the initial phase of a burn due to
hemoconcentration
