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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)

Causative agent and duration of exposure

Depth of burn

Anatomical location of burns on the body

Total Body Surface Area (TBSA) percentage

Time of day burn occurred

Answer and Explanation

Correct Answer : A,B,C,D

A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.

B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.

C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.

D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).

E. Time of day burn occurred – Time does not affect burn severity.

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Correct Answer is ["A","B"]

Explanation

A. Distributive shock

Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).

D. Hypovolemic shock

Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.

B. Cardiogenic shock

Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.

C. Obstructive shock

Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.

E. Neurogenic shock

Neurogenic shock occurs from spinal cord injuries, not burns.

A. White Blood Cell decrease B. Platelets increase C. Hemoglobin increase D. PT and INR normalize

Correct Answer is B

Explanation

A. White Blood Cell decrease
Platelet transfusions do not affect WBC levels. WBCs may change in response to infection or inflammation, but this is not an indicator of successful platelet transfusion.

B. Platelets increase
The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.

C. Hemoglobin increase
Hemoglobin levels increase after red blood cell (RBC) transfusions, not platelet transfusions.

D. PT and INR normalize
PT/INR measures clotting function, which is affected by clotting factors, not platelets. Platelet transfusions do not directly correct prolonged PT/INR.

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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

Correct Answer is ["A","B"]

Explanation

The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?

Correct Answer is B

Explanation

A heparin IV bolus is ordered: 80 units per kilogram. The unit's pharmacist prepares & labels a dose of heparin that is 5600 units. What is the patient's weight in kilograms? _______________

The nurse is preparing to start a transfusion of packed red blood cells. Which IV site should the nurse use?

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

Which of the following measures would the nurse emphasize to assist the client diagnosed with trigeminal neuralgia in managing their pain?

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)