Which assessment findings would alert the nurse to the presence of an inhalation?

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• Which assessment findings would alert you to the presence of an inhalation injury?
• Which of the following signs are indicators that an inhalation burn has occurred?
• Which finding would the nurse expect a patient with full
• Which complication would the nurse identify as a risk for a client with a burn injury?

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in trapped edema fluid, hemoconcentration that
leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.
84. A patient is admitted to the burn center with burns over his head, neck, chest, back, and left arm and hand after an explosion
and fire in his garage. On admission to the unit, you auscultate wheezes throughout the lung fields. On reassessment, you notice
that the wheezes are gone and the breath sounds are greatly diminished. Which of the following actions is the most appropriate
next step? 
a. place the pt in high fowler's position
b. encourage the pt to cough and auscultate the lungs again
c. document the results and continue to monitor the pt's progress
d. anticipate the need for endotracheal intubation and notify the physician: d. Anticipate the need for endotracheal intubation, and
notify the physician.
Inhalation injury results in exposure of respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or
carbon monoxide. You should anticipate the need for intubation.
85. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin
area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should
be cognizant of the risk of what complication?
A) Ischemia
B) Referred pain
C) Cellulitis
D) Venous thromboembolism (VTE): Ans: A
Feedback:
As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and
consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted
complications that occur distal to the injury site.
86. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the
lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.: ANS: B
The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so
that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the
problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur
87. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the
lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.: ANS: B
The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so
that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the
problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.
88. A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire.
Which of the following assessment findings would alert you to the presence of an inhalation injury (select all that apply)?
A.Singed nasal hair
B.Generalized pallor
C.Painful swallowing
D.Burns on the upper extremities
E.History of being involved in a large fire: a, c. Reliable clues to the occurrence of inhalation injury is the presence of facial burns,
singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned
in an enclosed space, and cherry red skin color
89. A patient is admitted with first- and second-degree burns covering the face, neck, entire right upper extremity, and the right
anterior trunk area. Using the rule of nines, the nurse would calculate the extent of these burns as being
A. 9%. 
B. 18%. 
C. 22.5%. 
D. 36%.: c. Using the rule of nines, the face and neck together encompass 4.5% of the body area; the right upper arm encompasses 9%
of the body area; and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of
the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together,
the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.
90. A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The
patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke
inhalation?
A) Pain
B) Fluid balance
C) Anxiety and fear
D) Airway management: Ans: D
Feedback:
Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While
all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.
91. A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the
epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these
assessment findings, what is the depth of the burn on the patient's arm?
A) Superficial partial-thickness
B) Deep partial-thickness
C) Full partial-thickness
D) Full-thickness: Ans: D
Feedback:
A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound
color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The
wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness
burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep
partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and
sensitivity to cold air. Full partial thickness is not a depth of burn.
92. A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major
burn injury is what?
A) Hemodynamic instability
B) Gastrointestinal hypermotility
C) Respiratory arrest
D) Hypokalemia: Ans: A
Feedback:
The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a
subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes.
Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not
take place in the initial phase of recovery.
93. A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to
Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
A) Promote truthful communication.
B) Avoid asking the patient to make decisions.
C) Teach the patient coping strategies.
D) Administer

Which assessment findings would alert you to the presence of an inhalation injury?

Which of the following signs are indicators that an inhalation burn has occurred?

Which finding would the nurse expect a patient with full

Which complication would the nurse identify as a risk for a client with a burn injury?