A nurse is assessing a patient with suspected fluid volume deficit (hypovolemia). Which of the following findings would be expected?
[a] Bradycardia, hypertension, and distended neck veins.
[b] Tachycardia, hypotension, and poor skin turgor.
[c] Bounding pulses, peripheral edema, and crackles in the lungs.
[d] Increased urine output and a low urine specific gravity.
A patient's ECG shows prominent peaked T-waves. The nurse should immediately assess the patient's lab results for which electrolyte imbalance?
[a] Hypokalemia.
[b] Hyponatremia.
[c] Hyperkalemia.
[d] Hypocalcemia.
An adult patient has sustained full-thickness burns to the entire anterior trunk and the entire left arm. Using the Rule of Nines, the nurse calculates the total body surface area (TBSA) percentage burned to be:
[a] 18%.
[b] 45%.
[c] 36%.
[d] 27%.
A positive Chvostek's sign (facial twitching) and Trousseau's sign (carpal spasm) are indicative of which electrolyte imbalance?
[a] Hypermagnesemia.
[b] Hypocalcemia.
[c] Hyperkalemia.
[d] Hyponatremia.
What is the absolute priority during the emergent (resuscitative) phase of burn management for a patient with burns to the face and neck?
[a] Pain management.
[b] Starting intravenous fluid resuscitation.
[c] Wound care.
[d] Maintaining a patent airway.
A patient is receiving an intravenous infusion of potassium chloride (KCl). Which nursing action is a critical safety measure?
[a] Administering the KCl via IV push for rapid correction.
[b] Ensuring the infusion rate does not exceed 10-20 mEq/hour.
[c] Mixing the KCl in a dextrose 5% in water (D5W) solution only.
[d] Hanging the KCl as a secondary (piggyback) infusion without a pump.
A patient with a burn injury develops blisters, severe pain, and a moist, weeping appearance to the wound. The nurse correctly classifies this burn as:
[a] Superficial (First-degree).
[b] Partial-thickness (Second-degree).
[c] Full-thickness (Third-degree).
[d] Deep full-thickness (Fourth-degree).
The most reliable method for monitoring a patient's fluid balance status on a daily basis is:
[a] Monitoring intake and output.
[b] Assessing skin turgor.
[c] Obtaining a daily weight.
[d] Checking for peripheral edema.
A patient with a history of heart failure is admitted with crackles in the lungs, jugular venous distention (JVD), and 3+ pitting edema. The nurse interprets these findings as which fluid imbalance?
[a] Fluid volume deficit.
[b] Fluid volume excess (hypervolemia).
[c] Isotonic dehydration.
[d] Third-spacing of fluid.
Which of the following IV solutions is considered isotonic and is frequently used for initial fluid resuscitation?
[a] 0.45% Sodium Chloride (1/2 NS).
[b] Dextrose 5% in Water (D5W).
[c] 0.9% Sodium Chloride (Normal Saline).
[d] 3% Sodium Chloride.
A nurse caring for a patient with a full-thickness burn notes the wound appears leathery and dry, with no sensation of pain. The nurse understands this is because:
[a] The patient has a high pain tolerance.
[b] The burn is not severe enough to cause pain.
[c] Nerve endings in the dermis have been destroyed.
[d] Edema is compressing the nerves.
A patient with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is at high risk for which electrolyte imbalance due to fluid retention?
[a] Dilutional hyponatremia.
[b] Hypernatremia.
[c] Hypokalemia.
[d] Hypercalcemia.
The Parkland (Baxter) formula is used in burn management to calculate the:
[a] Amount of pain medication required.
[b] Daily caloric needs for the patient.
[c] Percentage of total body surface area burned.
[d] Amount of intravenous fluid replacement needed in the first 24 hours.
A patient receiving the loop diuretic furosemide (Lasix) should be closely monitored for which electrolyte disturbance?
[a] Hypernatremia.
[b] Hypokalemia.
[c] Hypercalcemia.
[d] Hypermagnesemia.
Which assessment finding is a classic sign of an inhalation injury in a burn patient?
[a] Bradycardia.
[b] A loud, productive cough.
[c] Singed nasal hairs and a hoarse voice.
[d] A bright red rash on the chest.
A patient with chronic kidney disease has a serum magnesium level of 3.1 mEq/L (high). The nurse should prioritize assessing for:
[a] Hyperactive reflexes and tetany.
[b] Tachycardia and hypertension.
[c] Loss of deep tendon reflexes and respiratory depression.
[d] Seizures and confusion.
What is the immediate first aid intervention for a chemical burn to the skin?
[a] Apply an acidic solution to neutralize an alkaline burn.
[b] Cover the area tightly with a dry sterile dressing.
[c] Flush the area with copious amounts of cool water.
[d] Apply ice directly to the affected area.
A patient with severe dehydration is likely to have which laboratory finding?
[a] Decreased serum osmolality.
[b] Decreased hematocrit.
[c] Increased urine specific gravity.
[d] Decreased blood urea nitrogen (BUN).
The nutritional plan for a patient with a major burn injury should include:
[a] A low-calorie, low-protein diet to reduce metabolic stress.
[b] Fluid restriction to prevent edema.
[c] A high-calorie, high-protein diet to promote wound healing.
[d] A clear liquid diet for the first week.
A patient with severe hypernatremia, often caused by water loss, would be expected to exhibit which symptom?
[a] Apathy and muscle weakness.
[b] Abdominal cramping and diarrhea.
[c] Bounding pulses and hypertension.
[d] Intense thirst and altered mental status.
During the rehabilitative phase of burn care, the primary focus of nursing and physical therapy is to:
[a] Maintain fluid and electrolyte balance.
[b] Prevent joint contractures and maximize functional ability.
[c] Prevent wound infection.
[d] Manage acute pain.
A patient is receiving packed red blood cells. A few minutes into the infusion, the patient complains of flank pain and chills. The nurse's first action should be to:
[a] Administer an antihistamine.
[b] Slow the infusion rate.
[c] Stop the transfusion immediately.
[d] Check the patient's temperature.
Which of the following interventions would be included in the plan of care for a patient with severe hypercalcemia?
[a] Administering calcium gluconate IV.
[b] Promoting hydration and administering loop diuretics.
[c] Placing the patient on seizure precautions.
[d] Encouraging a diet high in dairy products.
Which of the following is an example of insensible fluid loss?
[a] Urine output.
[b] Emesis.
[c] Wound drainage.
[d] Water vapor from the lungs during respiration.
A patient with a major burn is at high risk for infection. The most important nursing intervention to prevent this complication is:
[a] Administering prophylactic pain medication.
[b] Practicing meticulous hand hygiene and aseptic wound care.
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