NCLEX Style Questions Burns, Med Surg - Burns NCLEX Exam Questions & Answers
(All Answers Explained!)
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that
the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term
would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery and the
area is painless because of the associated nerve destruction. Erythema, swelling, and
blisters point to a deep partial-thickness burn. With superficial partial-thickness burns,
the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching,
and pain
On admission to the burn unit, a patient with an approximate 25% total body surface area
(TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172
g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L).
Which action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion. - ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in
blood flow to the microcirculation unless fluid intake is increased. Because the
hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although
transfusions may be needed after the emergent phase once the patient's fluid balance has
been restored. On admission to a burn unit, the urine output would be monitored more
often than every 4 hours; likely every1 hour.
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
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland
formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL.
The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should
the nurse infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour - ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8
hours and the other half over the next 16 hours. In this case, the patient should receive
half of the initial rate, or 938 mL/hr.
During the emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The
patient's weight is not useful in this situation because of the effects of third spacing and
evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used,
but they are not as adequate in determining that fluid infusions are maintaining adequate
perfusion.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury.
To maintain adequate nutrition, the nurse should plan to take which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
,c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution. - ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and
increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will
be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus
that prevents adequate nutrient absorption. Vitamins and minerals 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 gastrointestinal
function, and is not routinely used in burn patients.
While the patient's full-thickness burn wounds to the face are exposed, what is the best
nursing action to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70° F (20° C) during dressing changes. -
ANS: B
Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility
of wound contamination for a patient whose burns are not covered. When removing
contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves.
The room temperature should be kept at approximately 85° F for patients with open burn
wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns
because of the lack of circulation.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and
hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck. - ANS: B
The right hand and arm should be elevated to reduce swelling and the fingers extended to
avoid flexion contractures (even though this position may not be comfortable for the
patient). The patient with burns of the ears should not use a pillow for the head because
this will 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.
, A patient with circumferential burns of both legs develops a decrease in dorsalis pedis
pulse strength and numbness in the toes. Which action should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes on both feet. - ANS: A
The decrease in pulse in a patient with circumferential burns indicates decreased
circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an
adequate response to the decrease in circulation. Elevating the legs or increasing toe
movement will not improve the patient's circulation
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5
days ago. Which nursing assessment would best evaluate the effectiveness of the
medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood - ANS: D
H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient
who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel
sounds, stool frequency, or appetite
The nurse is reviewing the medication administration record (MAR) on a patient with
partial-thickness burns. Which medication is best for the nurse to administer before
scheduled wound debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid) - ANS: D
Opioid pain medications are the best choice for pain control. The other medications are
used as adjuvants to enhance the effects of opioids.
A young adult patient who is in the rehabilitation phase after having deep partial-
thickness face and neck burns has a nursing diagnosis of disturbed body image. Which
statement by the patient indicates that the problem is resolving?
