NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review

Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25

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1. When assessing a patient who spilled hot ANS: B

oil on the right leg and foot, the nurse notes With full-thickness skin de-
that the skin is dry, pale, hard skin. The pa- struction, the appearance is
tient states that the burn is not painful. What pale and dry or leathery
term would the nurse use to document the and the area is painless
burn depth? because of the associat-
a. First-degree skin destruction ed nerve destruction. Ery-
b. Full-thickness skin destruction thema, swelling, and blisters
c. Deep partial-thickness skin destruction point to a deep partial-thick-
d. Superficial partial-thickness skin de- ness burn. With superficial
struction partial-thickness burns, the
area is red, but no blis-
ters are present. First-de-
gree burns exhibit erythema,
blanching, and pain

2. On admission to the burn unit, a patient with ANS: C

an approximate 25% total body surface area The patient's laboratory
(TBSA) burn has the following initial labora- data show hemoconcentra-
tory results: Hct 58%, Hgb 18.2 mg/dL (172 tion, which may lead to a de-
g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and crease in blood flow to the
serum Na+ 135 mEq/L (135 mmol/L). Which microcirculation unless fluid
action will the nurse anticipate taking now? intake is increased. Because
a. Monitor urine output every 4 hours. the hematocrit and hemo-
b. Continue to monitor the laboratory re- globin are elevated, a trans-
sults. fusion is inappropriate, al-
c. Increase the rate of the ordered IV solu- though transfusions may be
tion. needed after the emergent
d. Type and crossmatch for a blood transfu- phase once the patient's flu-
sion. id balance has been re-
stored. On admission to a
burn unit, the urine output
would be monitored more of-
ten than every 4 hours; likely
every1 hour.

3. A patient is admitted to the burn unit with ANS: B

burns to the head, face, and hands. Initially, The patient's history and
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 NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
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wheezes are heard, but an hour later, the clinical manifestations sug-
lung sounds are decreased and no wheezes gest airway edema and the
are audible. What is the best action for the health care provider should
nurse to take? be notified immediately, so
a. Encourage the patient to cough and aus- that intubation can be done
cultate the lungs again. rapidly. Placing the patient
b. Notify the health care provider and pre- in a more upright position
pare for endotracheal intubation. or having the patient cough
c. Document the results and continue to will not address the problem
monitor the patient's respiratory rate. of airway edema. Continu-
d. Reposition the patient in high-Fowler's ing to monitor is inappropri-
position and reassess breath sounds. ate because immediate ac-
tion should occur

4. A patient with severe burns has crystalloid ANS: C

fluid replacement ordered using the Park- Half of the fluid replacement
land formula. The initial volume of fluid to using the Parkland formula
be administered in the first 24 hours is is administered in the first
30,000 mL. The initial rate of administration 8 hours and the other half
is 1875 mL/hr. After the first 8 hours, what over the next 16 hours. In this
rate should the nurse infuse the IV fluids? case, the patient should re-
a. 350 mL/hour ceive half of the initial rate, or
b. 523 mL/hour 938 mL/hr.
c. 938 mL/hour
d. 1250 mL/hour

5. During the emergent phase of burn care, ANS: D

which assessment will be most useful in When fluid intake is ad-
determining whether the patient is receiving equate, the urine output
adequate fluid infusion? will be at least 0.5 to
a. Check skin turgor. 1 mL/kg/hour. The patient's
b. Monitor daily weight. weight is not useful in this sit-
c. Assess mucous membranes. uation because of the effects
d. Measure hourly urine output. of third spacing and evap-
orative fluid loss. Mucous
membrane assessment and
skin turgor also may be
used, but they are not as
2 / 46
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adequate in determining that
fluid infusions are maintain-
ing adequate perfusion.

6. A patient has just been admitted with a 40% ANS: A

total body surface area (TBSA) burn injury. Enteral feedings can usu-
To maintain adequate nutrition, the nurse ally be initiated during the
should plan to take which action? emergent phase at low rates
a. Insert a feeding tube and initiate enteral and increased over 24 to 48
feedings. hours to the goal rate. Dur-
b. Infuse total parenteral nutrition via a cen- ing the emergent phase, the
tral catheter. patient will be unable to eat
c. Encourage an oral intake of at least 5000 enough calories to meet nu-
kcal per day. tritional needs and may have
d. Administer multiple vitamins and miner- a paralytic ileus that pre-
als in the IV solution. vents adequate nutrient ab-
sorption. Vitamins and min-
erals may be administered
during the emergent phase,
but these will not assist in
meeting the patient's caloric
needs. Parenteral nutrition
increases the infection risk,
does not help preserve gas-
trointestinal function, and is
not routinely used in burn pa-
tients.

7. While the patient's full-thickness burn ANS: B

wounds to the face are exposed, what is the Use of gowns, caps, masks,
best nursing action to prevent cross conta- and gloves during all pa-
mination? tient care will decrease the
a. Use sterile gloves when removing old possibility of wound con-
dressings. tamination for a patient
b. Wear gowns, caps, masks, and gloves whose burns are not cov-
during all care of the patient. ered. When removing con-
c. Administer IV antibiotics to prevent bac- taminated dressings and
terial colonization of wounds. washing the dirty wound,
3 / 46
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d. Turn the room temperature up to at least use nonsterile, disposable
70° F (20° C) during dressing changes. gloves. The room temper-
ature should be kept at
approximately 85° F for
patients with open burn
wounds to prevent shiver-
ing. Systemic antibiotics are
not well absorbed into deep
burns because of the lack of
circulation.

8. A nurse is caring for a patient who has burns ANS: B

of the ears, head, neck, and right arm and The right hand and arm
hand. The nurse should place the patient in should be elevated to reduce
which position? swelling and the fingers ex-
a. Place the right arm and hand flexed in a tended to avoid flexion con-
position of comfort. tractures (even though this
b. Elevate the right arm and hand on pillows position may not be comfort-
and extend the fingers. able for the patient). The pa-
c. Assist the patient to a supine position tient with burns of the ears
with a small pillow under the head. should not use a pillow for
d. Position the patient in a side-lying posi- the head because this will
tion with rolled towel under the neck. put pressure on the ears,
and the pillow may stick to
the ears. Patients with neck
burns should not use a pillow
because the head should be
maintained in an extended
position in order to avoid
contractures.

9. A patient with circumferential burns of both ANS: A

legs develops a decrease in dorsalis pedis The decrease in pulse in a
pulse strength and numbness in the toes. patient with circumferential
Which action should the nurse take? burns indicates decreased
a. Notify the health care provider. circulation to the legs and
b. Monitor the pulses every 2 hours. the need for an escharoto-
c. Elevate both legs above heart level with my. Monitoring the pulses is
4 / 46
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pillows. not an adequate response to
d. Encourage the patient to flex and extend the decrease in circulation.
the toes on both feet. Elevating the legs or increas-
ing toe movement will not
improve the patient's circula-
tion

10. Esomeprazole (Nexium) is prescribed for ANS: D

a patient who incurred extensive burn in- H2 blockers and proton
juries 5 days ago. Which nursing assess- pump inhibitors are given
ment would best evaluate the effectiveness to prevent Curling's ulcer in
of the medication? the patient who has suffered
a. Bowel sounds burn injuries. Proton pump
b. Stool frequency inhibitors usually do not af-
c. Abdominal distention fect bowel sounds, stool fre-
d. Stools for occult blood quency, or appetite

11. The nurse is reviewing the medication ad- ANS: D

ministration record (MAR) on a patient with Opioid pain medications are
partial-thickness burns. Which medication the best choice for pain con-
is best for the nurse to administer before trol. The other medications
scheduled wound debridement? are used as adjuvants to en-
a. Ketorolac (Toradol) hance the effects of opioids.
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid)

12. A young adult patient who is in the rehabili- ANS: D

tation phase after having deep partial-thick- The willingness to use
ness face and neck burns has a nursing strategies to enhance ap-
diagnosis of disturbed body image. Which pearance is an indication
statement by the patient indicates that the that the disturbed body im-
problem is resolving? age is resolving. Expressing
a. "I'm glad the scars are only temporary." feelings about the scars in-
b. "I will avoid using a pillow, so my neck will dicates a willingness to dis-
be OK." cuss appearance, but not
c. "I bet my boyfriend won't even want to resolution of the problem.
look at me anymore." Because deep partial-thick-
5 / 46
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d. "Do you think dark beige makeup founda- ness burns leave permanent
tion would cover this scar on my cheek?" scars, a statement that the
scars are temporary indi-
cates denial rather than res-
olution of the problem. Avoid-
ing using a pillow will help
prevent contractures, but it
does not address the prob-
lem of disturbed body image

13. The nurse caring for a patient admitted with ANS: A

burns over 30% of the body surface as- The patient's urine output in-
sesses that urine output has dramatically dicates that the patient is
increased. Which action by the nurse would entering the acute phase of
best ensure adequate kidney function? the burn injury and moving
a. Continue to monitor the urine output. on from the emergent stage.
b. Monitor for increased white blood cells At the end of the emergent
(WBCs). phase, capillary permeabil-
c. Assess that blisters and edema have sub- ity normalizes and the pa-
sided. tient begins to diurese large
d. Prepare the patient for discharge from the amounts of urine with a
burn unit. low specific gravity. Although
this may occur at about
48 hours, it may be longer
in some patients. Blisters
and edema begin to resolve,
but this process requires
more time. White blood cells
may increase or decrease,
based on the patient's im-
mune status and any infec-
tious processes. The WBC
count does not indicate kid-
ney function. The patient will
likely remain in the burn unit
during the acute stage of
burn injury

6 / 46
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Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25
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14. A patient with burns covering 40% to- ANS: C
tal body surface area (TBSA) is in the A patient with a burn injury
acute phase of burn treatment. Which snack needs high protein and calo-
would be best for the nurse to offer to this rie food intake, and the milk-
patient? shake is the highest in these
a. Bananas nutrients. The other choices
b. Orange gelatin are not as nutrient-dense as
c. Vanilla milkshake the milkshake. Gelatin is like-
d. Whole grain bagel ly high in sugar. The bagel is
a good carbohydrate choice,
but low in protein. Bananas
are a good source of potas-
sium, but are not high in pro-
tein and calories.

15. A patient has just arrived in the emergency ANS: C

department after an electrical burn from ex- All patients with electrical
posure to a high-voltage current. What is the burns should be considered
priority nursing assessment? at risk for cervical spine in-
a. Oral temperature jury, and assessments of ex-
b. Peripheral pulses tremity movement will pro-
c. Extremity movement vide baseline data. The oth-
d. Pupil reaction to light er assessment data are also
necessary but not as essen-
tial as determining the cervi-
cal spine status

16. An employee spills industrial acids on both ANS: A

arms and legs at work. What is the priority With chemical burns, the
action that the occupational health nurse at initial action is to remove
the facility should take? the chemical from contact
a. Remove nonadherent clothing and watch. with the skin as quickly as
b. Apply an alkaline solution to the affected possible. Remove nonadher-
area. ent clothing, shoes, watch-
c. Place cool compresses on the area of es, jewelry, glasses, or con-
exposure. tact lenses (if face was ex-
d. Cover the affected area with dry, sterile posed). Flush chemical from
dressings. wound and surrounding area
7 / 46
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with copious amounts of
saline solution or water. Cov-
ering the affected area or
placing cool compresses on
the area will leave the chem-
ical in contact with the skin.
Application of an alkaline so-
lution is not recommended.

17. A patient who has burns on the arms, legs, ANS: D

and chest from a house fire has become Agitation in a patient who
agitated and restless 8 hours after being ad- may have suffered inhalation
mitted to the hospital. Which action should injury might indicate hypox-
the nurse take first? ia, and this should be as-
a. Stay at the bedside and reassure the pa- sessed by the nurse first.
tient. Administration of morphine
b. Administer the ordered morphine sulfate may be indicated if the nurse
IV. determines that the agitation
c. Assess orientation and level of con- is caused by pain. Assessing
sciousness. level of consciousness and
d. Use pulse oximetry to check the oxygen orientation is also appropri-
saturation. ate but not as essential as
determining whether the pa-
tient is hypoxemic. Reassur-
ance is not helpful to reduce
agitation in a hypoxemic pa-
tient

18. A patient arrives in the emergency depart- ANS: A

ment with facial and chest burns caused by A patient with facial and
a house fire. Which action should the nurse chest burns is at risk for in-
take first? halation injury, and assess-
a. Auscultate the patient's lung sounds. ment of airway and breath-
b. Determine the extent and depth of the ing is the priority. The oth-
burns. er actions will be completed
c. Infuse the ordered lactated Ringer's solu- after airway management is
tion. assured.

8 / 46
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d. Administer the ordered hydromorphone
(Dilaudid).

19. A patient with extensive electrical burn in- ANS: C

juries is admitted to the emergency depart- After an electrical burn, the
ment. Which prescribed intervention should patient is at risk for fatal
the nurse implement first? dysrhythmias and should be
a. Assess oral temperature. placed on a cardiac moni-
b. Check a potassium level. tor. Assessing the oral tem-
c. Place on cardiac monitor. perature is not as impor-
d. Assess for pain at contact points. tant as assessing for car-
diac dysrhythmias. Checking
the potassium level is im-
portant. However, it will take
time before the laboratory
results are back. The first
intervention is to place the
patient on a cardiac moni-
tor and assess for dysrhyth-
mias, so that they can be
treated if occurring. A de-
creased or increased potas-
sium level will alert the nurse
to the possibility of dysrhyth-
mias. The cardiac monitor
will alert the nurse imme-
diately of any dysrhythmias.
Assessing for pain is impor-
tant, but the patient can en-
dure pain until the cardiac
monitor is attached. Cardiac
dysrhythmias can be lethal.

20. Eight hours after a thermal burn cover- ANS: D

ing 50% of a patient's total body surface The urine output should be
area (TBSA) the nurse assesses the patient. at least 0.5 to 1.0 mL/kg/hr
Which information would be a priority to during the emergent phase,
communicate to the health care provider? when the patient is at great
9 / 46
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a. Blood pressure is 95/48 per arterial line. risk for hypovolemic shock.
b. Serous exudate is leaking from the burns. The nurse should notify the
c. Cardiac monitor shows a pulse rate of health care provider be-
108. cause a higher IV fluid rate
d. Urine output is 20 mL per hour for the past is needed. BP during the
2 hours. emergent phase should be
greater than 90 systolic, and
the pulse rate should be less
than 120. Serous exudate
from the burns is expected
during the emergent phase

21. Which patient should the nurse assess ANS: A

first? This patient has evidence of
a. A patient with smoke inhalation who has lower airway injury and hy-
wheezes and altered mental status poxemia and should be as-
b. A patient with full-thickness leg burns sessed immediately to de-
who has a dressing change scheduled termine the need for oxy-
c. A patient with abdominal burns who is gen or intubation. The oth-
complaining of level 8 (0 to 10 scale) pain er patients should also be
d. A patient with 40% total body surface area assessed as rapidly as pos-
(TBSA) burns who is receiving IV fluids at sible, but they do not have
500 mL/hour evidence of life-threatening
complications.

22. Which patient is most appropriate for the ANS: A

burn unit charge nurse to assign to a reg- An RN from a medical unit
istered nurse (RN) who has floated from the would be familiar with mal-
hospital medical unit? nutrition and with adminis-
a. A 34-year-old patient who has a weight tration and evaluation of re-
loss of 15% from admission and requires sponse to enteral feedings.
enteral feedings. The other patients require
b. A 67-year-old patient who has blebs under burn assessment and care
an autograft on the thigh and has an order that is more appropriate for
for bleb aspiration staff who regularly care for
c. A 46-year-old patient who has just come burned patients.
back to the unit after having a cultured ep-
ithelial autograft to the chest
10 / 46
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d. A 65-year-old patient who has twice-daily
burn debridements and dressing changes
to partial-thickness facial burns

23. A patient who was found unconscious in a ANS: D

burning house is brought to the emergency The patient's history and
department by ambulance. The nurse notes skin color suggest carbon
that the patient's skin color is bright red. monoxide poisoning, which
Which action should the nurse take first? should be treated by rapid-
a. Insert two large-bore IV lines. ly starting oxygen at 100%.
b. Check the patient's orientation. The other actions can be tak-
c. Assess for singed nasal hair and dark oral en after the action to correct
mucous membranes. gas exchange.
d. Place the patient on 100% oxygen using
a non-rebreather mask.

24. The nurse is reviewing laboratory results on ANS: C

a patient who had a large burn 48 hours ago. Hyperkalemia can lead to
Which result requires priority action by the fatal dysrhythmias and in-
nurse? dicates that the patient re-
a. Hematocrit 53% quires cardiac monitoring
b. Serum sodium 147 mEq/L and immediate treatment to
c. Serum potassium 6.1 mEq/L lower the potassium level.
d. Blood urea nitrogen 37 mg/dL The other laboratory values
are also abnormal and re-
quire changes in treatment,
but they are not as immedi-
ately life threatening as the
elevated potassium level

25. The charge nurse observes the following ANS: A

actions being taken by a new nurse on the Sterile gloves should be
burn unit. Which action by the new nurse worn when applying med-
would require an intervention by the charge ications or dressings to a
nurse? burn. Hypothermia is an in-
a. The new nurse uses clean latex gloves dicator of possible sepsis,
when applying antibacterial cream to a burn and cultures are appropriate.
wound. Nondiabetic patients may re-
11 / 46
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b. The new nurse obtains burn cultures quire insulin because stress
when the patient has a temperature of 95.2° and high calorie intake may
F (35.1° C). lead to temporary hyper-
c. The new nurse administers PRN fentanyl glycemia. Fentanyl peaks 5
(Sublimaze) IV to a patient 5 minutes before minutes after IV administra-
a dressing change. tion, and should be used just
d. The new nurse calls the health care before and during dressing
provider for a possible insulin order when a changes for pain manage-
nondiabetic patient's serum glucose is ele- ment
vated.

26. Which nursing action is a priority for a pa- ANS: B

tient who has suffered a burn injury while Cervical spine injuries are
working on an electrical power line? commonly associated with
a. Obtain the blood pressure. electrical burns. Therefore
b. Stabilize the cervical spine. stabilization of the cervical
c. Assess for the contact points. spine takes precedence af-
d. Check alertness and orientation. ter airway management. The
other actions are also includ-
ed in the emergent care after
electrical burns, but the most
important action is to avoid
spinal cord injury.

27. Which action will the nurse include in the ANS: D

plan of care for a patient in the rehabilitation Application of water-based
phase after a burn injury to the right arm and emollients will moisturize
chest? new skin and decrease flak-
a. Keep the right arm in a position of com- iness and itching. To avoid
fort. contractures, the joints of the
b. Avoid the use of sustained-release nar- right arm should be posi-
cotics. tioned in an extended posi-
c. Teach about the purpose of tetanus immu- tion, which is not the posi-
nization. tion of comfort. Patients may
d. Apply water-based cream to burned areas need to continue the use of
frequently. opioids during rehabilitation.
Tetanus immunization would
have been given during the
12 / 46
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emergent phase of the burn
injury

28. A young adult patient who is in the rehabil- ANS: B

itation phase 6 months after a severe face This response acknowl-
and neck burn tells the nurse, "I'm sorry edges the patient's feelings
that I'm still alive. My life will never be nor- and asks for more assess-
mal again." Which response by the nurse is ment data that will help in de-
best? veloping an appropriate plan
a. "Most people recover after a burn and feel of care to assist the patient
satisfied with their lives." with the emotional response
b. "It's true that your life may be different. to the burn injury. The other
What concerns you the most?" statements are accurate, but
c. "It is really too early to know how much do not acknowledge the anx-
your life will be changed by the burn." iety and depression that the
d. "Why do you feel that way? You will be patient is expressing.
able to adapt as your recovery progresses."

29. In which order will the nurse take these ac- ANS:
tions when doing a dressing change for a D, E, C, A, B
partial-thickness burn wound on a patient's Because partial-thickness
chest? (Put a comma and a space between burns are very painful, the
each answer choice [A, B, C, D, E].) nurse's first action should be
a. Apply sterile gauze dressing. to administer pain medica-
b. Document wound appearance. tions. The wound will then be
c. Apply silver sulfadiazine cream. cleaned, antibacterial cream
d. Administer IV fentanyl (Sublimaze). applied, and covered with
e. Clean wound with saline-soaked gauze a new sterile dressing. The
last action should be to doc-
ument the appearance of the
wound.

30. An 80-kg patient with burns over 30% of 600 mL

total body surface area (TBSA) is admitted The Parkland formula states
to the burn unit. Using the Parkland formula that patients should receive
of 4 mL/kg/%TBSA, what is the IV infusion 4 mL/kg/%TBSA burned
rate (mL/hour) for lactated Ringer's solution during the first 24 hours. Half
of the total volume is given
13 / 46
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that the nurse will administer during the first in the first 8 hours and then
8 hours? the last half is given over 16
hours: 4 80 30 = 9600 mL
total volume; 9600/2 = 4800
mL in the first 8 hours; 4800
mL/8 hr = 600 mL/hr.

31. A patient comes into the emergency de- Correct Answer: 1,2
partment with a chemical burn from contact Rationale: This is an alkali
with lye.Assessment and treatment of this burn which is more difficult to
patient will be based on what knowledge neutralize than an acid burn
regarding this type of burn? (Select all that and tends to have a deeper
apply) penetration and be more se-
1. This is an alkali burn. vere than a burn caused by
2. This type of burn tends to be deeper. an acid.
3. This is an acid burn.
4. This type of burn will be easier to neutral-
ize.
5. This type of burn tends to be more super-
ficial.

32. Knowing the most common causes of 1. Correct answer: c

household fires, which prevention strategy
would the nurse focus on when teaching Rationale: A risk-reduction
about fire safety? strategy for household fires
is to encourage regular
a. Set hot water temperature at 140 degrees home fire exit drills. Hot wa-
F ter heaters set at 140° F (60°
b. Use only hardwired smoke detectors C) or higher are a burn haz-
c. Encourage regular home fire exit drills ard in the home; the tem-
d. Never permit older adults to cook unat- perature should be set at
tended less than 120° F (40° C).
Installation of smoke and
carbon monoxide detectors
can prevent inhalation in-
juries. Hard-wired smoke de-
tectors do not require battery
replacement; battery-operat-
14 / 46
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ed smoke detectors may be
used. Supervision of older
adults who are cooking is
necessary only if cognitive
alterations are observed.

33. A nurse is caring for a patient with sec- B. One half of the to-
ond- and third-degree burns to 50% of the tal 24-hour fluid requirement
body. The nurse prepares fluid resuscitation should be administered in
based on knowledge of the Parkland (Bax- the first 8 hours.
ter) formula that includes which recommen-
dation? Fluid resuscitation with the
Parkland (Baxter) formula
A. The total 24-hour fluid requirement recommends that one half
should be administered in the first 8 hours. of the total fluid requirement
B. One half of the total 24-hour fluid require- should be administered in
ment should be administered in the first 8 the first 8 hours, one quar-
hours. ter of total fluid requirement
C. One third of the total 24-hour fluid re- should be administered in
quirement should be administered in the the second 8 hours, and
first 4 hours. one quarter of total fluid re-
D. One half of the total 24-hour fluid require- quirement should be admin-
ment should be administered in the first 4 istered in the third 8 hours.
hours.

34. A patient arrives at the emergency depart- Correct Answer: 1,2,3

ment with an electrical burn. What assess- Rationale: The severity of
ment questions should the nurse ask in de- electrical burns depends on
termining the possible severity of the burn the type and duration of the
injury? Select all that apply. current and amount of volt-
1. What type of current was involved? age. Location is not impor-
2. How long was the patient in contact with tant in determining possible
the current? severity. Location is not im-
3. How much voltage was involved? portant in determining possi-
4. Where was the patient when the burn oc- ble severity.
curred?
5. What was the point of contact with the
current?
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35. The nurse is caring for a patient with su- B. Reddening of the skin
perficial partial-thickness burns of the face
sustained within the last 12 hours. Upon The clinical appearance of
assessment the nurse would expect to find superficial partial-thickness
which manifestation? burns includes erythema,
blanching with pressure, and
A. Blisters pain and minimal swelling
B. Reddening of the skin with no vesicles or blistering
C. Destruction of all skin layers during the first 24 hours.
D. Damage to sebaceous glands

36. The injury that is least likely to result in a Correct answer: a

full-thickness burn is:
Rationale: Full-thickness
a. sunburn burns may be caused by
b. scald injury contact with flames, scald-
c. chemical burn ing liquids, chemicals, tar, or
d. electrical injury electrical current.

37. A nurse sees a patient get struck by light- Correct Answer: 1

ning during a thunder storm on a golf Rationale: Cardiopulmonary
course. What should be the FIRST action by arrest is the most common
the nurse? cause of death from lighten-
1. Check breathing and circulation. ing. Respiratory and cardiac
2. Look for entrance and exit wounds. status should be assessed
3. Cover the patient to prevent heat loss. immediately to determine if
4. Move the patient indoors to a dry place. CPR is necessary. All other
5. Get the patient up off the ground. actions are secondary.

38. The nurse is planning care for a patient with A, C, D, E.

partial- and full-thickness skin destruction
related to burn injury of the lower extremi- An escharotomy (a scalpel
ties. Which interventions should the nurse incision through full-thick-
expect to include in this patient's care? (Se- ness eschar) is frequently
lect all that apply.) required to restore circula-
tion to compromised extrem-
A. Escharotomy ities. Daily cleansing and de-
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B. Administration of diuretics bridement as well as ap-
C. IV and oral pain medications plication of an antimicrobial
D. Daily cleansing and debridement ointment are expected inter-
E. Application of topical antimicrobial agent ventions used to minimize in-
fection and enhance wound
healing. Pain control is es-
sential in the care of a pa-
tient with a burn injury. With
full-thickness burns, myo-
globin and hemoglobin re-
leased into the bloodstream
can occlude renal tubules.
Adequate fluid replacement
is used to prevent this occlu-
sion.

39. When assessing a patient with a par- Correct answers: a, d, e

tial-thickness burn, the nurse would expect
to find (SATA): Rationale: The appearance
of partial-thickness (deep)
a. blisters burns may include fluid-filled
b. exposed fascia vesicles (blisters) that are
c. exposed muscles red, shiny, or wet (if vesicles
d. intact nerve endings have ruptured). Patients may
e. red, shiny, wet appearance have severe pain caused by
exposure of nerve endings
and may have mild to mod-
erate edema.

40. A patient is admitted to the burn center Correct answer: d

with burns of his head and neck, chest, and
back after an explosion in his garage. On Rationale: Inhalation injury
assessment, the nurse auscultates wheezes results in exposure of the
throughout the lung fields. On reassess- respiratory tract to intense
ment, the wheezes are gone and the breath heat or flames with inhala-
sounds are greatly diminished. Which ac- tion of noxious chemicals,
tion is the most appropriate for the nurse to smoke, or carbon monox-
take next? ide. The nurse should an-
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ticipate the need for intuba-
a. obtain vital signs and a STAT ABG tion and mechanical ventila-
b. encourage the patient to cough and aus- tion because this patient is
cultate the lungs again demonstrating signs of se-
c. document the findings and continue to vere respiratory distress.
monitor the patient's breathing
d. anticipate the need for endotracheal intu-
bation and notify the physician

41. A nurse is teaching a class of older adults Correct Answer: 1,2,3,4

at a senior center about household cleaning Rationale: All of the prod-
agents that may cause burns. Which agents ucts except for the furni-
should be included in these instructions? ture polish can cause burns
(Select all that apply) since they are either alkalis
1. drain cleaners or acids.
2. household ammonia
3. oven cleaner
4. toiler bowl cleaner
5. lemon oil furniture polish

42. The nurse is caring for a patient with partial- D. High-calorie and high-pro-
and full-thickness burns to 65% of the body. tein foods
When planning nutritional interventions for
this patient, what dietary choices should the A hypermetabolic state oc-
nurse implement? curs proportional to the size
of the burn area. Mas-
A. Full liquids only sive catabolism can oc-
B. Whatever the patient requests cur and is characterized
C. High-protein and low-sodium foods by protein breakdown and
D. High-calorie and high-protein foods increased gluconeogenesis.
Caloric needs are often in
the 5000-kcal range. Failure
to supply adequate calories
and protein leads to malnu-
trition and delayed healing.

43. A patient, experiencing a burn that is pale Correct Answer: 1

and waxy with large flat blisters, asks the Rationale: The wound de-
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nurse about the severity of the burn and scribed is a deep par-
how long it will take to heal. With which of tial-thickness burn. Deep
the following should the nurse respond to partial-thickness wounds will
this patient? take more than three weeks
1. The wound is a deep partial-thickness to heal. A superficial burn
burn, and will take more than three weeks is bright red and moist, and
to heal. might appear glistening with
2. The wound is a partial-thickness burn, blister formation. The heal-
and could take up to two weeks to heal. ing time for this type of
3. The wound is a superficial burn, and will wound is within 21 days. A
take up to three weeks to heal. full thickness burn involves
4. The wound is a full-thickness burn and all layers of the skin and
will take one to two weeks to heal. may extend into the underly-
5. Wound healing is individualized. ing tissue. These burns take
many weeks to heal. Stating
that wound healing is individ-
ualized does not answer the
patient's question about the
severity of the burn.

44. A patient is admitted to the emergency A, B, C, E.

department with first- and second-degree
burns after being involved in a house fire. Reliable clues to the oc-
Which assessment findings would alert you currence of inhalation in-
to the presence of an inhalation injury? (se- jury is the presence of fa-
lect all that apply)? cial burns, singed nasal hair,
hoarseness, painful swal-
A. Singed nasal hair lowing, darkened oral and
B. Generalized pallor nasal membranes, carbona-
C. Painful swallowing ceous sputum, history of be-
D. Burns on the upper extremities ing burned in an enclosed
E. History of being involved in a large fire space, altered mental status,
and "cherry red" skin color.

45. Fluid and electrolyte shifts that occur dur- Correct answer: c
ing the early emergent phase of a burn in-
jury include: Rationale: During the emer-
gency phase, sodium rapid-
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a. adherence of albumin to vascular walls ly shifts to the interstitial
b. movement of potassium into vascular spaces and remains there
space until edema formation ceas-
c. sequestering of sodium and water in in- es.
terstitial fluid
d. hemolysis of red blood cells from large
volumes of rapidly administered fluid

46. In order for the nurse to correctly classify a Correct Answer: 1,2,3,4
burn injury, which of the following does the Rationale: Depth of the burn
nurse need to assess? (the layers of underlying tis-
Select all that apply. sue affected) and extent of
1. the depth of the burn the burn (the percentage
2. extent of burns on the body of body surface area in-
3. the causative agent and the duration of volved) are used in deter-
exposure. mining the amount of tissue
4. location of burns on the body damage and classification
5. the time that the burn occurred of the burn.The causative
agent is especially important
with chemical burns such as
from strong acids or alka-
line agents. The location of
the burns on the body is
one of the important deter-
minates of classification. For
example, burns of the face
and hands are always con-
sidered major burns. Time of
occurrence of the burn is not
necessary for classification.

47. When caring for a patient with an electrical C. Lactated Ringer's at 25

burn injury, which order from the health care mL/hr
provider should the nurse question?
Electrical injury puts the pa-
A. Mannitol 75 gm IV tient at risk for myoglobin-
B. Urine for myoglobulin uria, which can lead to acute
C. Lactated Ringer's at 25 mL/hr renal tubular necrosis (ATN).
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D. Sodium bicarbonate 24 mEq every 4 Treatment consists of infus-
hours ing lactated Ringer's at 2-4
mL/kg/%TBSA, a rate suffi-
cient to maintain urinary out-
put at 75 to 100 mL/hr. Man-
nitol can also be used to
maintain urine output. Sodi-
um bicarbonate may be giv-
en to alkalinize the urine.
The urine would also be
monitored for the presence
of myoglobin. An infusion
rate of 25 mL/hr is not suf-
ficient to maintain adequate
urine output in prevention
and treatment of ATN.

48. To maintain a positive nitrogen balance in a Correct answer: a

major burn, the patient must:
Rationale: The patient
a. eat a high-protein, low-fat, high-carbohy- should be encouraged to
drate diet eat high-protein, high-carbo-
b. increase normal caloric intake by about hydrate foods to meet in-
three times creased caloric needs. Mas-
c. eat at least 1500 calories/day in small, sive catabolism can oc-
frequent meals cur and is characterized
d. eat rice and whole wheat for the chemical by protein breakdown and
effect on nitrogen balance. increased gluconeogenesis.
Failure to supply adequate
calories and protein leads
to malnutrition and delays in
healing.

49. A patient has 25% TBSA burned from a car Correct answer: b
fire. His wounds have been debrided and Rationale: Infection is the
covered with a silver-impregnated dressing. most serious threat with re-
The nurse's priority intervention for wound gard to further tissue injury
care would be to: and possible sepsis.
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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.

50. A patient is admitted with second- and B. 22.5%

third-degree burns covering the face, en-
tire right upper extremity, and the right an- Using the rule of nines, for
terior trunk area. Using the rule of nines, these second- and third-de-
what should the nurse calculate the extent gree burns, the face encom-
of these burns as being? passes 4.5% of the body
area, the entire right arm en-
A. 18% compasses 9% of the body
B. 22.5% area, and the entire anteri-
C. 27% or trunk encompasses 18%
D. 36% of the body area. Since the
patient has burns on only
the right side of the ante-
rior trunk, the nurse would
assess that burn as encom-
passing half of the 18%,
or 9%. Therefore adding the
three areas together (4.5 +
9 + 9), the nurse would cor-
rectly calculate the extent of
this patient's burns to cover
approximately 22.5% of the
total body surface area.

51. A patient has a scald burn on the arm that is Correct Answer: 1,2
bright red, moist, and has several blisters. Rationale: Superficial par-
The nurse would classify this burn as which tial-thickness burn if often
of the following? bright red, has a moist, glis-
Select all that apply. tening appearance and blis-
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1. a superficial partial-thickness burn ter formation. Thermal burns
2. a thermal burn result from exposure to dry
3. a superficial burn or moist heat. A superficial
4. a deep partial-thickness burn burn is reddened with pos-
5. a full-thickness burn sible slight edema over the
area. A deep partial-thick-
ness burn often appears
waxy and pale and may be
moist or dry. A full-thick-
ness burn may appear pale,
waxy, yellow, brown, mot-
tled, charred, or non-blanch-
ing red with a dry, leathery,
firm wound surface.

52. A patient is brought to the emergency de- Correct Answer: 22.5

partment with the following burn injuries: a Rationale : The anterior
blistered and reddened anterior trunk, red- trunk has superficial par-
dened lower back, and pale, waxy anterior tial-thickness burns and is
right arm. Calculate the extent of the burn calculated in TBSA as 18%.
injury (TBSA) using the rule of nines. The arm has a deep par-
tial-thickness burn and is
calculated as 4.5%. The
burn on the lower back is su-
perficial and is not calculated
in TBSA.

53. An 82-year-old patient is moving into an in- C. Install tap water anti-scald
dependent living facility. What is the best ad- devices.
vice the nurse can give to the family to help
prevent this patient from being accidentlyInstalling tap water
burned in her new home? anti-scald devices will help
prevent accidental scald
A. Cook for her. burns that more easily occur
B. Stop her from smoking. in older people as their skin
C. Install tap water anti-scald devices. becomes drier and the der-
D. Be sure she uses an open space heater. mis thinner. Cooking for her
may be needed at times of ill-
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ness or in the future, but she
is moving to an independent
living facility, so at this time
she should not need this as-
sistance. Stopping her from
smoking may be helpful to
prevent burns but may not
be possible without the re-
quirement by the facility. Us-
ing an open space heater
would increase her risk of
being burned and would not
be encouraged.

54. Pain management for the burn patient is Correct answers: a, c, d

most effective when (SATA):
Rationale: The use of a pain
a. a pain rating tool is used to monitor the rating tool assists the nurse
patient's level of pain in the assessment, monitor-
b. painful dressing changes are delayed un- ing, and evaluation of the
til the patient's pain is completely relieved pain management plan. The
c. the patient is informed about and has more control the patient has
some control over the management of the in managing the pain, the
pain more successful the cho-
d. a multi-modal approach is used (e.g., sen strategies are. A se-
sustained-release and short-acting opioids, lected variety of medications
NSAIDS, adjuvant analgesics). offer better pain relief for
e. non-pharmacological therapies (e.g., mu- patients with burns, whose
sic therapy, distraction) replace opioids in pain can be both contin-
the rehabilitation phase of a burn injury uous and treatment relat-
ed over varying periods of
time. It is not realistic to
promise a patient that pain
will be completely eliminat-
ed. It is not realistic to sug-
gest that pain will be man-
aged (during any phase of
burn care) with nonpharma-
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cologic pain management.
Such management is meant
to be adjuvant and individu-
alized.

55. A 25-year-old patient is admitted with par- Correct Answer: 1

tial-thickness injuries over 20% of the total Rationale 1: A moder-
body surface area involving both lower legs. ate burn is a partial-thick-
The nurse would classify this injury as be- ness injury that is between
ing which of the following? 15%-25% of total body sur-
1. a moderate burn face area in adults.
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn

56. The ambulance reports that they are trans- D. No pain, waxy white skin,
porting a patient to the ED who has experi- and no blanching with pres-
enced a full-thickness thermal burn from a sure
grill. What manifestations should the nurse
expect? With full-thickness burns, the
nerves and vasculature in
A. Severe pain, blisters, and blanching with the dermis are destroyed so
pressure there is no pain, the tis-
B. Pain, minimal edema, and blanching with sue is dry and waxy-look-
pressure ing or may be charred,
C. Redness, evidence of inhalation injury, and there is no blanch-
and charred skin ing with pressure. Severe
D. No pain, waxy white skin, and no blanch- pain, blisters, and blanch-
ing with pressure ing occur with partial-thick-
ness (deep, second-degree)
burns. Pain, minimal ede-
ma, blanching, and red-
ness occur with partial-thick-
ness (superficial, first-de-
gree) burns.

57.
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A therapeutic measure used to prevent Correct answer: a
hypertrophic scarring during rehabilitation Rationale: Pressure can
phase of burn recover is: help keep a scar flat and
reduce hypertrophic scar-
a. applying pressure garments ring. Gentle pressure can be
b. repositioning the patient every 2 hours maintained on the healed
c. performing active ROM at least every 4 burn with custom-fitted pres-
hours sure garments.
d. massaging the new tissue with wa-
ter-based moisturizers

58. A patient is recovering from second- and Correct answer: c

third-degree burns over 30% of his body and
is now ready for discharge. The first action Rationale: Recovery from a
the nurse should take when meeting with burn injury to 30% of total
the patient would be to: body surface area (TBSA)
takes time and is exhausting,
a. arrange a return-to-clinic appointment both physically and emo-
and prescription for pain medications tionally, for the patient. The
b. teach the patient and caregiver proper health care team may think
wound care to be performed at home that a patient is ready for dis-
c. review the patient's current health care charge, but the patient may
status and readiness for discharge to home not have any idea that dis-
d. give the patient written discharge infor- charge is being contemplat-
mation and websites for additional informa- ed in the near future. Pa-
tion for burn survivors. tients are often very fearful
about how they will manage
at home. The patient would
benefit from the nurse's
careful review of his or her
progress and readiness for
discharge; then the nurse
should outline the plans for
support and follow-up after
discharge.

59. In caring for a patient with burns to the back, D. Diuresis occurs and
the nurse knows that the patient is moving hematocrit decreases.
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out of the emergent phase of burn injury
when what happens? In the emergent phase,
the immediate, life-threaten-
A. Serum sodium and potassium increase ing problems from the burn,
B. Serum sodium and potassium decrease. hypovolemic shock and ede-
C. Edema and arterial blood gases improve. ma, are treated and re-
D. Diuresis occurs and hematocrit decreas- solved. Toward the end of the
es. emergent phase, fluid loss
and edema formation end.
Interstitial fluid returns to the
vascular space and diure-
sis occurs. Urinary output is
the most commonly used pa-
rameter to assess the ade-
quacy of fluid resuscitation.
The hemolysis of RBCs and
thrombosis of burned capil-
laries also decreases circu-
lating RBCs. When the fluid
balance has been restored,
dilution causes the hemat-
ocrit levels to drop. Initially
sodium moves to the inter-
stitial spaces and remains
there until edema formation
ceases, so sodium levels in-
crease at the end of the
emergent phase as the sodi-
um moves back to the vas-
culature. Initially potassium
level increases as it is re-
leased from injured cells and
hemolyzed RBCs, so potas-
sium levels decrease at the
end of the emergent phase
when fluid levels normalize.

60.
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A patient has sustained a partial-thickness Correct Answer: 1
injury of 28% of total body surface area Rationale 1: Partial-thick-
(TBSA) and full-thickness injury of 30% or ness injuries of greater than
greater of TBSA. How should the nurse clas- 25% of total body surface
sify this burn injury? area in adults and full-thick-
1. major ness injuries 10% or greater
2. moderate of TBSA are considered ma-
3. minor jor burns.
4. superficial
5. intermediate

61. A 70-year-old patient has experienced a Correct Answer: 1

sunburn over much of the body. What Rationale: Older adults are
self-care technique is MOST important to especially prone to dehy-
emphasize to an older adult in dealing with dration; therefore, increas-
the effects of the sunburn? ing fluid intake is especially
1. increasing fluid intake important. Other manifesta-
2. applying mild lotions tions could include nausea
3. taking mild analgesics and vomiting. All the mea-
4. maintaining warmth sures help alleviate the man-
5. using sunscreen ifestations of this minor burn
which include pain, skin red-
ness, chills, and headache.
Use of sunscreen is a pre-
ventative, not a treatment
measure.

62. When teaching the patient about the use of B, C.

range-of-motion (ROM), what explanations
should the nurse give to the patient? Select Active and passive ROM
all that apply. maintains function of body
parts and reassures the
A. The exercises are the only way to prevent patient that movement is
contractures. still possible are the ex-
B. Active and passive ROM maintain func- planations that should be
tion of body parts. used. Contractures are pre-
C. ROM will show the patient that movement vented with ROM as well
is still possible. as splints. Movement facil-
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D. Movement facilitates mobilization of itates mobilization of fluid
leaked exudates back into the vascular bed. in interstitial fluid back into
E. Active and passive ROM can only be done the vascular bed. Although
while the dressings are being changed. it is good to collaborate
with physical therapy to per-
form ROM during dressing
changes because the pa-
tient has already taken anal-
gesics, ROM can and should
be done throughout the day.

63. A patient is being discharged after treat- Correct Answer: 1,2,3

ment for a scald burn that caused a super- Rationale: Fever or purulent
ficial burn over one hand and a superficial drainage are indicative of de-
partial-thickness burn on several fingers. velopment of infection and
What should be included in this patient's should be reported to the
discharge instructions? healthcare provider. Sterile
(Select all that apply) dressings only should be
1. Report any fever to your healthcare used on the areas of the
provider. superficial partial-thickness
2. Report development of purulent drainage burns where the skin is not
to your healthcare provider. intact. Cleansing is neces-
3. Use only sterile dressings on the fingers. sary no more often than daily
4. Cleanse the areas every hour with alcohol to the intact skin areas and
to prevent infection. only soap and water should
5. Apply the topical antimicrobial agent as be used, not alcohol. Topical
instructed. agents may be ordered by
the health care provider and
the patient should follow di-
rections for applying to help
prevent infection of the ar-
eas.

64. During the care of the patient with a burn B. Monitor for signs of com-
in the acute phase, which new interventions plications.
should the nurse expect to do after the pa-
tient progressed from the emergent phase? Monitoring for complica-
tions (e.g., wound infection,
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A. Begin IV fluid replacement. pneumonia, contractures) is
B. Monitor for signs of complications. needed in the acute phase.
C. Assess and manage pain and anxiety. Fluid replacement occurs in
D. Discuss possible reconstructive surgery. the emergent phase. As-
sessing and managing pain
and anxiety occurs in the
emergent and the acute
phases. Discussing possi-
ble reconstructive surgeries
is done in the rehabilitation
phase.

65. A patient is being evaluated after experi- Correct Answer: 1

encing severe burns to his torso and upper Rationale: Burn shock oc-
extremities. The nurse notes edema at the curs during the first 24-36
burned areas. Which of the following best hours after the injury. During
describes the underlying cause for this as- this period, there is an in-
sessment finding? crease in microvascular per-
1. inability of the damaged capillaries to meability at the burn site.
maintain fluids in the cell walls The osmotic pressure is in-
2. reduced vascular permeability at the site creased, causing fluid accu-
of the burned area mulation. There is a reduc-
3. decreased osmotic pressure in the tion of fluids in the extra-
burned tissue cellular body compartments.
4. increased fluids in the extracellular com- Manifestations of fluid vol-
partment ume overload would be sys-
5. the IV fluid being administered too quickly temic, not localized to the
burn areas.

66. The patient in the acute phase of burn care C. Maintain fluid balance.
has electrical burns on the left side of her
body, type 2 diabetes mellitus, and a serum This patient is most like-
glucose level of 485 mg/dL. What should ly experiencing hyperosmo-
be the nurse's priority intervention to pre- lar hyperglycemic syndrome
vent a life-threatening complication of hy- (HHS). HHS dehydrates a
perglycemia for this burned patient? patient rapidly. Thus HHS
combined with the massive
A. Replace the blood lost. fluid losses of a burn tremen-
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B. Maintain a neutral pH. dously increase this patient's
C. Maintain fluid balance. risk for hypovolemic shock
D. Replace serum potassium. and serious hypotension.
This is clearly the nurse's pri-
ority because the nurse must
keep up with the patient's
fluid requirements to prevent
circulatory collapse caused
by low intravascular volume.
There is no mention of blood
loss. Fluid resuscitation will
help to correct the pH and
serum potassium abnormal-
ities.

67. A patient with a burn inhalation injury B. Tachycardia

is receiving albuterol (Ventolin) for bron-
chospasm. What is the most important ad- Albuterol (Ventolin) stimu-
verse effect of this medication for the nurse lates ²-adrenergic receptors
to manage? in the lungs to cause bron-
chodilation. However, it is
A. GI distress a non-cardioselective agent
B. Tachycardia so it also stimulates the ²--
C. Restlessness receptors in the heart to in-
D. Hypokalemia crease the heart rate. Rest-
lessness and GI upset may
occur but will decrease with
use. Hypokalemia does not
occur with albuterol.

68. A patient receiving treatment for severe Correct Answer: 1

burns over more than half of his body has Rationale: The patient will
an indwelling urinary catheter. When evalu- have an initial reduction in
ating the patient's intake and output, which urinary output. Fluid is re-
of the following should be taken into con- duced in the initial phases
sideration? as the body manages the
1. The amount of urine will be reduced in the insult caused by the injury
first 24-48 hours, and will then increase. and fluids are drawn into the
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2. The amount of urine output will be great- interstitial spaces. After the
est in the first 24 hours after the burn injury. shock period passes, the pa-
3. The amount of urine will be reduced dur- tient will enter a period of
ing the first eight hours of the burn injury diuresis. The diuresis begins
and will then increase as the diuresis be- between 24 and 36 hours af-
gins. ter the burn injury.
4. The amount of urine will be elevated due
to the amount of intravenous fluids adminis-
tered during the initial phases of treatment.
5. The amount of urine is expected to be
decreased for three to five days.

69. The nurse is reviewing the results of labo- Correct Answer: 1,2
ratory tests to assess the renal status of a Rationale: During the ini-
patient who experienced a major burn event tial phases of a burn injury,
on 45% of the body 24 hours ago. Which of blood flow to the renal sys-
the following results would the nurse expect tem is reduced, resulting in
to see? reduction in GFR and an
(Select all that apply) increase in specific gravity.
1. glomerular filtration rate (GFR) reduced During this period, BUN lev-
2. specific gravity elevated els, creatinine, and uric acid
3. creatinine clearance reduced are increased
4. BUN reduced
5. uric acid decreased

70. The patient in the emergent phase of a burn B. IV morphine sulfate

injury is being treated for pain. What med-
ication should the nurse anticipate using for IV medications are used for
this patient? burn injuries in the emer-
gent phase to rapidly deliv-
A. SQ tetanus toxoid er relief and prevent unpre-
B. IV morphine sulfate dictable absorption as would
C. IM hydromorphone (Dilaudid) occur with the IM route. The
D. PO oxycodone and acetaminophen (Per- PO route is not used be-
cocet) cause GI function is slowed
or impaired due to shock or
paralytic ileus, although oxy-
codone and acetaminophen
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may be used later in the pa-
tient's recovery. Tetanus tox-
oid may be administered but
not for pain.

71. When evaluating the laboratory values of Correct Answer: 1

the burn-injured patient, which of the follow- Rationale: Hemoglobin lev-
ing can be anticipated? els are reduced in response
1. decreased hemoglobin and elevated to the hemolysis of red blood
hematocrit levels cells. Hematocrit levels are
2. elevated hemoglobin and elevated hema- elevated secondary to he-
tocrit levels moconcentration, and fluid
3. elevated hemoglobin and decreased shifts from the intravascular
hematocrit levels compartment.
4. decreased hemoglobin and decreased
hematocrit levels
5. hemoglobin and hematocrit levels within
normal ranges

72. The patient received a cultured epithelial C. Refer the patient to a

autograft (CEA) to the entire left leg. What counselor for psychosocial
should the nurse include in the discharge support.
teaching for this patient?
In the rehabilitation phase,
A. Sit or lay in the position of comfort. the patient will work to-
B. Wear a pressure garment for 8 hours each ward resuming a functional
day. role in society, but frequently
C. Refer the patient to a counselor for psy- there are body image con-
chosocial support. cerns and grieving for the
D. Use the sun to increase the skin color on loss of the way they looked
the healed areas. and functioned before the
burn, so continued counsel-
ing helps the patient in this
phase as well. Putting the leg
in the position of comfort is
more likely to lead to con-
tractures than to help the pa-
tient. If a pressure garment
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is prescribed, it is used for
24 hours per day for as long
as 12 to 18 months. Sunlight
should be avoided to prevent
injury, and sunscreen should
always be worn when the pa-
tient is outside.

73. When caring for a patient with an electrical c.

burn injury, which order from the health care
provider should the nurse question? An infusion rate of 25 mL/hr
is not sufficient to main-
a. mannitol 75 gm IV tain adequate urine output in
b. urine for myoglobulin prevention and treatment of
c. LR at 25 mL/h ATN.
d. sodium bicarbonate 24 mEq q.4h Electrical injury puts the pa-
tient at risk for myoglobin-
uria, which can lead to acute
renal tubular necrosis (ATN).
Treatment consists of infus-
ing lactated Ringer's at 2-4
mL/kg/%TBSA, a rate suffi-
cient to maintain urinary out-
put at 75 to 100 mL/hr. Man-
nitol can also be used to
maintain urine output. Sodi-
um bicarbonate may be giv-
en to alkalinize the urine.
The urine would also be
monitored for the presence
of myoglobin.

74. When monitoring the vital signs of the pa- Correct Answer: 1
tient who has experienced a major burn in- Rationale: The burn-injured
jury, the nurse assesses a heart rate of 112 patient is not considered
and a temperature of 99.9° F. Which of the tachycardic until the heart
following best describes the findings? rate reaches 120 beats per
1. These values are normal for the patient's minute. In the absence of
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post-burn injury condition. other symptoms, the temper-
2. The patient is demonstrating manifesta- ature does not signal the
tions consistent with the onset of an infec- presence of an infection. It
tion. could be a response to a hy-
3. The patient is demonstrating manifesta- permetabolic response.
tions consistent with an electrolyte imbal-
ance.
4. The patient is demonstrating manifesta-
tions consistent with renal failure.
5. The patient is demonstrating manifesta-
tions of fluid volume overload.

75. A patient is admitted with second- and b.

third-degree burns covering the face, en-
tire right upper extremity, and the right an- Using the rule of nines, for
terior trunk area. Using the rule of nines, these second- and third-de-
what should the nurse calculate the extent gree burns, the face encom-
of these burns as being? passes 4.5% of the body
area, the entire right arm en-
a. 18% compasses 9% of the body
b. 22.5% area, and the entire anteri-
c. 27% or trunk encompasses 18%
d. 36% of the body area. Since the
patient has burns on only
the right side of the ante-
rior trunk, the nurse would
assess that burn as encom-
passing half of the 18%,
or 9%. Therefore adding the
three areas together (4.5 +
9 + 9), the nurse would cor-
rectly calculate the extent of
this patient's burns to cover
approximately 22.5% of the
total body surface area.

76. A patient has experienced a burn injury. Correct Answer: 1

Which of the following interventions by the Rationale: Determination of
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nurse is of the highest priority at this time? the type of burn is the
1. determination of the type of burn injury first step. The type of in-
2. determination of the types of home reme- jury will dictate the interven-
dies attempted prior to the patient's coming tions performed. Determin-
to the hospital ing the use of home reme-
3. assessment of past medical history dies, past medical history,
4. determination of body weight body weight, and nutritional
5. determination of nutritional status status must be completed,
but are not of the highest pri-
ority.

77. A patient is scheduled for surgery to graft Correct Answer: 1

a burn injury on the arm. Which of the fol- Rationale: The patient
lowing statements should the nurse include will begin to perform
when instructing the patient prior to the pro- range-of-motion exercises
cedure? after five days. Itching is not
1. "You will begin to perform exercises to a symptom of infection but
promote flexibility and reduce contractures an anticipated occurrence
after five days." that signals cellular growth.
2. "You will need to report any itching, as it The ideal time to perform
might signal infection." the procedure is early in the
3. "Performing the procedure near the end of treatment of the burn injury.
the hospitalization will reduce the incidence The procedure is performed
of infection and improve success of the pro- in a surgical suite. Patients
cedure." with skin grafts do not re-
4. "The procedure will be performed in your quire protective isolation.
room."
5. "You will need to be in protective iso-
lation for several weeks after the graft is
performed."

78. A patient recovering from a major burn in- Correct Answer: 1

jury is complaining of pain. Which of the fol- Rationale: Morphine is pre-
lowing medications will be most therapeutic ferred over meperidine for
to the patient? the burn-injured patient. Typ-
1. morphine 4 mg IV every 5 minutes ical dose of morphine is 3-5
2. morphine 10 mg IM ever 3-4 hours mg every 5-10 minutes for an
3. meperidine 75 mg IM every 3-4 hours adult. The intravenous route
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4. meperidine 50 mg PO every 3-4 hours is preferred over oral and in-
5. fentanyl citrate (Duragesic) 75 mcg patch tramuscular routes. A trans-
every 3 days dermal patch would not be
used because of decreased
absorption of the medica-
tion through the skin of the
burn-injured patient.

79. A patient with a burn injury is prescribed Correct Answer: 1,2

silver nitrate. Which of the following nursing Rationale: Silver nitrate can
interventions should be included for the pa- cause hypotonicity. Manifes-
tient? tations of hypotonicity in-
Standard Text: Select all that apply. clude weight gain and ede-
1. Monitor daily weight. ma, which can be monitored
2. Monitor the serum sodium levels. by the determination of daily
3. Prepare to change the dressings every weights. Hyponatremia and
two hours. hypochloremic alkalosis are
4. Report black skin discolorations. common findings in patients
5. Push fluid intake. treated with silver nitrate
so serum sodium and chlo-
ride should be monitored.
Changing the dressing every
two hours is too frequent
for the patient. Black discol-
orations of the skin are antic-
ipated for patients using sil-
ver nitrate, and do not high-
light a complication of ther-
apy. Silver sulfadiazine, not
silver nitrate, administration
can result in the develop-
ment of sulfa crystals in the
urine so pushing fluid intake
is not an appropriate action
for this patient.

80. When teaching the patient about the use of b, c

range-of-motion (ROM), what explanations
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should the nurse give to the patient? (select Active and passive ROM
all that apply)? maintains function of body
parts and reassures the
a. the exercises are the only way to prevent patient that movement is
contractures still possible are the ex-
planations that should be
b. active and passive ROM maintain func- used. Contractures are pre-
tion of body parts vented with ROM as well
as splints. Movement facil-
c. ROM will show the patient that movement itates mobilization of fluid
is still possible in interstitial fluid back into
the vascular bed. Although
d. movement facilitates mobilization of it is good to collaborate
leaked exudates back into the vascular bed. with physical therapy to per-
form ROM during dressing
e. active and passive ROM can only be done changes because the pa-
while the dressings are being changed tient has already taken anal-
gesics, ROM can and should
be done throughout the day.

81. The nurse is evaluating the adequacy of Correct Answer: 1

a burn-injured patient's nutritional intake. Rationale: Glucose in the
Which of the following laboratory values is urine is seen after a ma-
the best indicator of a need to adjust the jor burn injury. It signals the
nutritional program? need to reevaluate the pa-
1. glycosuria tient's nutritional plan. Crea-
2. creatine phosphokinase (CPK) tine phosphokinase is used
3. BUN levels to identify the presence of
4. hemoglobin muscle injuries. BUN levels
5. serum sodium levels are used to evaluate kidney
function. Hemoglobin levels
will fluctuate with the stages
of the burn injury dependent
upon the fluid status. Serum
sodium levels are not indica-
tive of nutritional status.

82.
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During the acute phase of burn treatment, Correct Answer: 1,2,3,4
important goals of patient care include Rationale: The goals of treat-
which of the following? ment for the acute peri-
Select all that apply. od include wound cleans-
1. providing for patient comfort ing and healing; pain re-
2. preventing infection lief; preventing infection; pro-
3. providing adequate nutrition for healing moting nutrition; and splint-
to occur ing, positioning, and exercis-
4. splinting, positioning, and exercising af- ing affected joints. Assess-
fected joints ment of home maintenance
5. assessing home maintenance manage- management is an impor-
ment tant goal in the rehabilitative
stage, not the acute stage.

83. A patient is admitted to the emergency de- Correct Answer: 1

partment with deep partial-thickness burns Rationale: Warmed lactated
over 35 % of the body. What IV solution will Ringer's solution is the IV
be started initially? solution of choice because
1. warmed lactated Ringer's solution it most closely approximates
2. dextrose 5% with saline solution the body's extracellular fluid
3. dextrose 5% with water composition. It is warmed to
4. normal saline solution prevent hypothermia.
5. 0.45% saline solution

84. A patient with a burn inhalation injury b.

is receiving albuterol (Ventolin) for bron-
chospasm. What is the most important ad- Albuterol (Ventolin) stimu-
verse effect of this medication for the nurse lates ²-adrenergic receptors
to manage? in the lungs to cause bron-
chodilation. However, it is
a. GI distress a non-cardioselective agent
b. tachycardia so it also stimulates the ²--
c. restlessness receptors in the heart to in-
d. hypokalemia crease the heart rate. Rest-
lessness and GI upset may
occur but will decrease with
use. Hypokalemia does not
occur with albuterol.
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85. Using the modified Brooke formula, calcu- Correct Answer: 2080 mL
late the amount of intravenous solution that Rationale : The modified
will be administered in the first 8 hours for Brooke formula is 2 mL × to-
a patient with 40% TBSA and weighs 52 kg. tal kg of body weight × %
TBSA. In this situation, 2 mL
× 52 kg × 40 = 4160 mL.
One-half is given over the
first eight hours, or 2080 mL.

86. Place an "X" over the section of the dia- Rationale : A superficial par-
gram that represents the depth of a super- tial-thickness burn damages
ficial partial-thickness burn. [insert Use fig- the entire epidermis and
ure 16-17 in LeMone 5E. Remove the caption through the papillary dermis.
and the labels on the right side (Clark's lev-
els). Retain the left side labels (Skin layers).
The Roman numeral labels in the drawing
may remain if necessary.]

87. The patient received a cultured epithelial c.

autograft (CEA) to the entire left leg. What
should the nurse include in the discharge In the rehabilitation phase,
teaching for this patient? the patient will work to-
ward resuming a functional
a. sit or lay in the position of comfort role in society, but frequently
b. wear a pressure garment for 8 hours each there are body image con-
day cerns and grieving for the
c. refer the patient to a counselor for phy- loss of the way they looked
chosocial support and functioned before the
d. use the sun to increase the skin color on burn, so continued counsel-
the healed areas ing helps the patient in this
phase as well. Putting the leg
in the position of comfort is
more likely to lead to con-
tractures than to help the pa-
tient. If a pressure garment
is prescribed, it is used for
24 hours per day for as long
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as 12 to 18 months. Sunlight
should be avoided to prevent
injury, and sunscreen should
always be worn when the pa-
tient is outside.

88. The family of a patient with third-degree Correct Answer: 1

burns wants to know why the "scabs are Rationale: The patient's fam-
being cut off" of the patient's leg. What is ily is describing eschar,
the most appropriate response by the nurse which is the hard crust of
to this family? burned necrotic tissue. Es-
1. "The scabs are really old burned tissue char needs to be removed to
and need to be removed to promote heal- promote wound healing. Op-
ing." tion 2 does not answer the
2. "I'll ask the doctor to come and talk with family's question. Option 3
you about the treatment plan." incorrectly restates the fam-
3. "The patient asked for the scabs to be ily's concern. Scabs are not
removed." removed to check for blood
4. "The scabs are removed to check for flow.
blood flow to the burned area."

89. A patient with third-degree burns is pre- Correct Answer: 1

scribed gastrointestinal medication. The pri- Rationale: Dysfunction of the
mary action of this drug is which of the gastrointestinal system is di-
following? rectly related to the size of
1. to prevent the onset of a Curling's ulcer the burn wound. This can
2. to treat a preexisting duodenal ulcer lead to a cessation of intesti-
3. to ensure adequate peristalsis nal motility, which causes
4. for the antiemetic properties gastric distention, nausea,
vomiting, and hematemesis.
Stress ulcers or Curling's ul-
cers are acute ulcerations of
the stomach or duodenum
that form following the burn
injury. There is no evidence
to support the presence of
a preexisting duodenal ulcer.
Although peristalsis is de-
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sired, it is not the primary
area of gastrointestinal con-
cern. There is no data pre-
sented to indicate the pres-
ence of nausea or vomiting.

90. A patient is coming into the emergency de- Correct Answer: 1

partment with third-degree burns over 25% Rationale: Warmed Ringer's
of his body. The nurse should prepare which lactate solution is the in-
of the following solutions for intravenous travenous fluid most wide-
infusion for this patient? ly used during the first 24
1. warmed lactated Ringer's hours after a burn injury be-
2. 5% dextrose in water cause it most closely approx-
3. 5% dextrose in 0.45 normal saline imates the body's extracellu-
4. 5% dextrose in normal saline lar fluid composition.

91. The nurse notes that a patient with third-de- Correct Answer: 1
gree burns is demonstrating a reduction in Rationale: Potassium levels
his serum potassium level. The nurse re- are initially elevated during
alizes that this finding is consistent with burn shock but will decrease
which of the following? after burn shock resolves as
1. the resolution of burn shock fluid shifts back to intracel-
2. the onset of burn shock lular and intravascular com-
3. the onset of renal failure partments. Reduced potas-
4. the onset of liver failure sium levels are not indicators
of the onset of renal or liver
failure.

92. A patient who is being treated with topical Correct Answer: 1

mafenide acetate for third-degree burns is Rationale: Approximately
demonstrating facial and neck edema. The 3%-5% of patients develop a
nurse realizes that this patient most likely hypersensitivity to mafenide,
1. is developing a hypersensitivity to the which can manifest as facial
medication. edema. The manifestation of
2. is reacting positively to the medication. facial and neck edema is
3. needs an increase in dosage of the med- considered an adverse reac-
ication. tion. There is inadequate in-
4. is not responding to the medication. formation presented to as-
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sess response to the med-
ication.

93. Following surgical debridement, a patient Correct Answer: 1

with third-degree burns does not bleed. The Rationale: Surgical debride-
nurse realizes that this patient ment is the process of ex-
1. will need to have the procedure repeated. cising the burn wound by
2. will no longer need this procedure. removing thin slices of the
3. will need to be premedicated prior to the wound to the level of viable
next procedure. tissue. If bleeding does not
4. should have an escharotomy instead. occur after the procedure, it
will be repeated. It is an as-
sumption that patients hav-
ing debridement will all re-
quire premedication. An es-
charotomy involves removal
of the hardened crust cover-
ing the burned area.

94. The nurse is providing care to a patient with Correct Answer: 1

a third-degree burn on his left thigh and Rationale: Enzymatic de-
left forearm. During wound care, the nurse bridement involves the use
applies Elase to the burned areas. Which of of a topical agent to dis-
the following types ofwound debridement is solve and remove necrotic
this nurse using? tissue. An enzyme such as
1. enzymatic Elase is applied in a thin
2. mechanical layer directly to the wound
3. surgical and covered with one layer
4. topical of fine mesh gauze. A topical
antimicrobial agent is then
applied and covered with a
bulky wet dressing. Mechan-
ical debridement may be
performed by applying and
removing gauze dressings,
hydrotherapy, irrigation, or
using scissors and tweez-
ers. Surgical debridement is
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the process of excising the
wound to the fascia or re-
moving thin slices of the burn
to the level of viable tissue.
Topical treatments are key in
the care of a burn but do not
involve debridement.

95. A patient with third-degree burns is being Correct Answer: 1

treated with high-volume intravenous fluids Rationale: Intake and output
and has a urine output of 40 cc per hour. The measurements indicate the
nurse realizes that this urine output adequacy of fluid resuscita-
1. is normal for this patient. tion, and should range from
2. provides evidence that the patient is de- 30 to 50 mL per hour in an
hydrated. adult.
3. provides evidence that the patient is
over-hydrated.
4. is indicative of pending renal failure.

96. A patient with third-degree burns to his right Correct Answer: 1

arm is scheduled for passive range of mo- Rationale: The nurse should
tion to the extremity every two hours. Which anticipate this patient's
of the following should the nurse do prior to needs for analgesia and ad-
this exercise session? minister pain medication to
1. Medicate for pain. promote the patient's com-
2. Empty the patient's in-dwelling catheter fort during the exercise ses-
collection bag. sion. Arm exercise is not
3. Change the patient's bed linens. related to the amount of
4. Change the dressing on the burn. urine in the catheter bag.
Linen changes do not im-
pact range of motion ac-
tivities. The burn's dress-
ing is changed according to
the physician's orders or as
needed.

97. A patient with third-degree burns to her face Correct Answer: 1

just learned that she will have extensive Rationale: This patient can
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scarring once the burn heals. Which of the begin to experience power-
following nursing diagnoses would be ap- lessness in that she has no
plicable to this patient at this time? control over the outcome of
1. Powerlessness healing on scar formation to
2. Potential for Infection her face. The nurse should
3. Fluid Volume Deficit allow the patient to express
4. Risk for Ineffective Airway Clearance feelings in efforts to help the
patient cope with the news
of potential scarring. The pa-
tient with a third-degree burn
is at risk for infection, how-
ever, this question is focused
on the impact of her fa-
cial scarring. There is inad-
equate information to deter-
mine the patient's risk for flu-
id volume deficit or ineffec-
tive airway clearance. Fur-
ther, this is not the focus of
the question.

98. A patient comes into the clinic to be seen for Correct Answer: 2
a burn that appears moist with blisters. The Rationale: Partial-thickness,
nurse realizes that this patient most likely or second-degree, burns
has experienced which of the following? can either be superficial or
1. first-degree burn deep. This patient's burn,
2. superficial second-degree burn which appears moist with
3. deep second-degree burn blisters, is consistent with
4. third-degree burn a superficial second-degree
burn. A first-degree burn
would involve only the sur-
face layer of skin. Redness
would be expected. Deep
second-degree and third-de-
gree burns would be deeper
and involve more damage to
the dermis, epidermis, and
underlying tissue.
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 NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25
Burns
Study online at https://quizlet.com/_7d6zwa

99. A female patient comes into the clinic Correct Answer: 4

complaining of nausea and vomiting after Rationale: Sunburns result
spending the weekend at a seaside resort. from exposure to ultraviolet
Which of the following should be the most light. Because the skin re-
important assessment for the nurse? mains intact, the manifes-
1. normal rest and sleep pattern tations in most cases are
2. typical meal pattern mild and are limited to pain,
3. if the patient had to change time zones nausea, vomiting, skin red-
when traveling to the resort ness, chills, and headache.
4. if the patient has been sunburned The patient has not report-
ed concerns which will sup-
port issues with sleep pat-
tern, diet, and travel.

100. A patient comes into the physician's office Correct Answer: 3

after sustaining chemical burns to the left Rationale: Adult patients
side of his face and right wrist. The nurse who should be treated at
realizes that this patient needs to be treated burn centers include those
1. in the outpatient ambulatory clinic. with burns that involve the
2. in the emergency department. hands, feet, face, eyes, ears,
3. in a burn center. or perineum. Patients having
4. in the doctor's office and then at home. small or noninvasive burns
may be managed at an out-
patient clinic are mild in na-
ture. The emergency depart-
ment is a location for eval-
uation of a burn. The physi-
cian's office like the ambula-
tory clinic can manage mild
burns.

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