NUR 213 NCLEX Questions Burns
1. A client arriving at the emergency department has experienced frostbite to the right hand.
Which finding would the nurse note on assessment of the client's hand?
1.
A pink, edematous hand
2.
Fiery red skin with edema in the nail beds
3.
Black fingertips surrounded by an erythematous rash
4.
A white color to the skin, which is insensitive to touch
Answer
4
Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and
insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or
blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.
2. An adult client was burned in an explosion. The burn initially affected the client's entire face
(anterior half of the head) and the upper half of the anterior torso, and there were circumferential
burns to the lower half of both arms. The client's clothes caught on fire, and the client ran,
causing subsequent burn injuries to the posterior surface of the head and the upper half of the
posterior torso. Using the rule of nines, what would be the extent of the burn injury?
1.
18%
2.
24%
3.
36%
4.
48%
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, Answer
3. 36%
According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the
upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The
subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of
posterior torso, equaling 9%. This totals 36%.
3. The nurse is preparing to care for a burn client scheduled for an escharo- tomy procedure
being performed for a third-degree circumferential arm burn. The nurse understands that which
finding is the anticipated therapeutic out- come of the escharotomy?
1.
Return of distal pulses
2.
Brisk bleeding from the site
3.
Decreasing edema formation
4.
Formation of granulation tissue
Answer
1. Return of distal pulses
Escharotomies are performed to relieve the compartment syndrome that can occur when edema
forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy
releases the tourniquet-like compression around the arm.
Escharotomies are performed through avascular eschar to subcutaneous fat. Al- though bleeding
may occur from the site, it is considered a complication rather than an anticipated therapeutic
outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but
occasionally an artery is damaged and may require ligation. Escharotomy does not affect the
formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
4. The nurse is caring for a client who sustained superficial partial-thickness burns on the
anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the
resuscitation/emergent phase of the burn injury?
1.
Decreased heart rate
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