1.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the
skin is dry, pale, 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

2. Marvin 30y/o male was admitted to the burn unit with an approximate 25% total body surface
area (TBSA) burn has the following initial laboratory results:
Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135
mEq/L (135 mmol/L).
Which action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion

3. Nurse Even is caring for a young adult patient who is in the rehabilitation phase after having
deep partial-thickness face and neck burns and has a nursing diagnosis of disturbed body
image. Which statement by the patient indicates that the problem is resolving?
a. "I'm glad the scars are only temporary."
b. "I will avoid using a pillow, so my neck will be OK."
c. "I bet my boyfriend won't even want to look at me anymore."
d. "Do you think a dark beige makeup foundation would cover this scar on my cheek?"

4. Nurse Ralph is duty at the emergency room. A patient arrives with facial and chest burns
caused by a house fire. Which action should the nurse most appropriate to take first?
a. Auscultate the patient’s lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringer’s solution.
d. Administer the pain medication as ordered.

5. Nurse mike nurse duty in the burn unit. A patient who has burns on the arms, legs, and chest
from a house fire, suddenly Eron notices the pt 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 sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.

6. Nurse Roceth is doing wound dressing in a patient with 25% total body surface area burned
from a car fire. His wounds have been debrided and covered with a silver-
impregnated dressing. The nurse's priority intervention for wound care would be to:
 a. reapply a new dressing without disturbing the wound bed
b. observe the wound for signs of infection during dressing changes
c. apply cool compresses for pain relief in between dressing changes
d. wash the wound aggressively with soap and water three times a day.

7. Nurse Marites, an Emergency Room nurse received a call form a rescuer and that they are
transporting a patient to the ER who has experienced a full-thickness burn caused by an gas
explosion. What manifestations should the nurse expect?
a. Severe pain, blisters, and blanching with pressure
b. Pain, minimal edema, and blanching with pressure
c. Redness, evidence of inhalation injury, and charred skin
d. No pain, waxy white skin, and no blanching with pressure

8. Nurse Ralph is assessing a 20 years old patient, admitted in a burn unit with second- and
third-degree burns covering the face, entire right upper extremity, and the right anterior trunk
area. Using the rule of nines, he calculates the total body surface
area affected, sustained by the patient from burn?
a. 18%
b. 22.5%
c. 27%
d. 36%

9. A 25-year-old female patient has sustained burns to the back of the right arm, posterior trunk,
front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate
the total body surface area percentage that is burned?
a. 46%
b. 37%
c. 36%
d. 28%

10. As a knowledgeable nurse in patient with burn. A 70-year-old patient has experienced a
sunburn over much of the body. What self-care technique is MOST important to emphasize to
an older adult in dealing with the effects of the sunburn?
a. increasing fluid intake
b. applying mild lotions
c. taking mild analgesics
d. maintaining warmth

11.As a nurse charged in caring for a patient admitted with burns over 30% of the body surface.
You notice that urine output has dramatically increased. Which action by the nurse would best
ensure adequate kidney function?
a. Continue to monitor the urine output.
b. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
 d. Prepare the patient for discharge from the burn unit.

12. A 65 kg adult male sustains a 15% TBSA burn. Calculate the total IV fluid requirement for
the first 24 hours using the Parkland Formula.
a. 3900
b. 2500
c. 3000
d. 4000

13. A nurse is reading a physician's progress notes in the client's record and reads that the
physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse
understands that this type of fluid loss can occur through
a. The GIT
b. Urinary output
c. Wound drainage
d. The skin

14. The movement of fluids in the where it starts from Higher concentration to lower
concentrations?
a. Osmotic
b. Diffusion
c. Active transport
d. Filtration

15. The direction of fluids in the body where from lower to higher concentration?
a. Osmotic
b. Diffusion
c. Active transport
d. Filtration

16. A patient is diagnosed with hypokalemia. After reviewing the patient's current medications,
which of the following might have contributed to the patient's health problem?
a. corticosteroid
b. thiazide diuretic
c. narcotic
d. muscle relaxer

17. The nurse obtains all of the following assessment data about a patient with deficient fluid
volume caused by a massive burn injury. Which of the following assessment data will be of
greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 ml over the last hour.
c. Oral fluid intake is 100 ml for the last 8 hours.
d. There are prolonged skin tenting over the sternum.
18. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as
a. personality changes.
b. frequent loose stools.
c. facial muscle spasms.
d. generalized weakness.

19. A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority
for this patient?
a. Start oxygen at 2 L/min
b. Initiate cardiac monitoring
c. Initiate seizure precautions
d. Keep the patient on bed rest

20. The nurse is caring for an older adult with hypernatremia. Which of these interventions does
the nurse perform first?
a. Restrict the client’s intake of sodium
b. Administer a diuretic
c. Monitor the serum osmolarity
d. Encourage fluid intake

21. After obtaining an EKG on a patient you notice that ST depression is present along with an
inverted T wave and prominent U wave. What lab value would be the cause of this finding?
a. Magnesium level of 2.2
b. Potassium level of 5.6
c. Potassium level of 2.2
d. Phosphorus level of 2.0

22. As the nurse caring for a patient with chloride level of 118 meq/L. What intravenous fluid
would you expect the attending physician will order?
a. 3% NS
b. D5NS
c. Lactated Ringers IVF
d. 0.45 % Normal Saline

23. While checking the laboratory results, the assigned nurse noted that the serum potassium
level of his patient is 5.7 mEq/L. The nurse then checked the latest ECG strip of the patient,
which is expected to show:
Select all that apply.
a. Widened QRS interval
b. Inverted T waves
c. Tall, peaked T waves
d. Prominent U-waves
24. A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon
palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What
interventions do you expect the medical doctor to order for this patient?
a. Restrict fluid intake and monitor daily weights
b. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor
urinary output
c. Administer hypotonic IV fluid and administer sodium tablets.
d. No interventions are expected

25. 25. A 56 year old male patient was brought to the emergency
department due to acute episodes of hallucinations as stated by his wife. Upon evaluation of his
laboratory findings the serum calcium level is 7.1 mg/dL. What other signs and symptoms
should be expected with this patient.

Select all that apply.

1. Irritability
2. Seizure
3. Positive Chostek's sign
4. Muscle cramps
5. Hypoactive bowel sounds

a. 1,2,3 & 4
b. 1,2,4 & 5
c. 1,3 & 5
d. 1,4 & 5

26. Which of the following is a common symptom of hypernatremia?

a. Muscle weakness
b. Confusion
c. Bradycardia
d. Hyporeflexia

27. After obtaining an EKG on a patient you notice that ST depression is present along with an
inverted T wave and prominent U wave. What lab value would be the cause of this finding?
a. Magnesium level of 2.2
b. Potassium level of 5.6
c. Potassium level of 2.2
d. Phosphorus level of 2.0

28. Which patient below would have a potassium level of 5.5?

a. A 76 year old who reports taking Lasix (Furosemide) four times a day
b. A patient with Addison's disease
c. A 55 year old woman who have been vomiting for 3 days consistently
 d. A patient with liver failure

29. A patient is receiving intravenous fluids postoperatively following cardiac surgery. Nursing
assessments should focus on which postoperative complication?
a. fluid volume excess
b. fluid volume deficit
c. seizure activity
d. liver failure

30. The nurse reviews the care needs for a group of clients. Which condition should the nurse
realize occurs from a fluid volume deficit?
a. Diarrhea
b. Water intoxication
c. Kidney failure
d. Hypertension