A patient with circumferential burns on both legs develops a decrease in dorsalis pedis pulses strength and numbness in the toes. Which action should the nurse take first? A. Monitor the pulses every hour B. Notify the health care provider C. Elevate both legs above heart level with pillows D. Enco...
NU 214 Exam 3 Test Questions and
Correct Answers
A patient with circumferential burns on both legs develops a decrease in dorsalis pedis
pulses strength and numbness in the toes. Which action should the nurse take first?
A. Monitor the pulses every hour
B. Notify the health care provider
C. Elevate both legs above heart level with pillows
D. Encourgae the patient to flew and extend toes ✅B. Notify the health care provider
On admission to the burn unit, a patient with an approximate 25% total body surface
area (TBSA) burn has the following inital laboratory results: HCT 58%, Hgb 18.2 mg/dL,
(172 g/L), serum K+ 4.9 mEq/L (4.8mmol/L). Which of the following prescribed actions
should be the nurses priority?
A. Monitor the urine output every 4 hours
B. Continue to monitor the laboratory results
C. Increasing the rate of the ordered IV solution
D. Typing and crossmatching for a blood transfusion ✅C. Increasing the rate of the
ordered IV solution
Esomeprazole (Nexium) is prescribed for a patient who incurred extenssive burn injuries
5 days ago. Which nursing assessment would best evaluate the effectiveness of the
drug?
A. Bowel sounds
B. Stool frequency
C. Stool Occult blood
D. Abdominal distention ✅C. Stool Occult blood
A patient who has burns n the arms, legs, , and chest from a house fire has become
agitated and restless 8 hours after being admitted to the hospital. Which action should
the nurse take first?
A. Stay at the bedside and reassure the patient
B. Administer the ordered morphine sulphate IV
C. Assess orientation and level of consciousness
D. Use pulse oximetry to check oxygen saturation ✅D. Use pulse oximetry to check
oxygen saturation
Eight hours after a thermal burn covering 50% of a patients total body surface area
(TBSA), the nurse assesses the patient. The patient weighs 92kg (202.4 lbs). Which
information would be a priority to communicate to the health care provider?
A. Blood pressure is 95/48 per arterial line
B. Urine output of 41ml over the past 2 hours
C. Serous exudate is leaking from the burns
, D. Heart monitor shows sinus tachycardia of 108 ✅B. Urine output of 41ml over the
past 2 hours
In which order will the nurse take these actions when doing a dressing change for a
partial thickness burn wound on a patients chest? (put a comma and a space between
each)
A. Apply sterile gauze dressing
B. Document wound appearance
C. Apply silver sulfadiazine cream
D. Give IV fentanyl (Sublimaze)
E. Clean wound with saline soaked gauze ✅D, E, C, A, B
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes
dry, pale, and hard skin. The patient states that the burn is not painful. What term would
the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction ✅b. Full-thickness skin destruction
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially,
wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes
are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds. ✅b.
Notify the health care provider and prepare for endotracheal intubation.
A patient with severe burns has crystalloid fluid replacement ordered using the
Parklandformula. The initial volume of fluid to be administered in the first 24 hours is
30,000 mL. Theinitial rate of administration is 1875 mL/hr. After the first 8 hours, what
rate should the nurse infuse the IV fluids?
a. 219 mL/hr
b. 625 mL/hr
c. 938 mL/hr
d. 1875 mL/hr ✅c. 938 mL/hr
During the emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. ✅d. Measure hourly urine output.
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