NCLEX StyLE PraCtiCE QuEStioNS BurNS,
MEd Surg - BurNS NCLEX rEviEw
QuEStioNS, MEd Surg EXaM 3 BurNS
QuEStioNS, MEd Surg: ChaPtEr 25 BurNS
uPdatEd 2025/2026
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 - Answer-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. - Answer-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. -
Answer-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 - Answer-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.
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.
- Answer-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. -
Answer-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.
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. - Answer-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
MEd Surg - BurNS NCLEX rEviEw
QuEStioNS, MEd Surg EXaM 3 BurNS
QuEStioNS, MEd Surg: ChaPtEr 25 BurNS
uPdatEd 2025/2026
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 - Answer-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. - Answer-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. -
Answer-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 - Answer-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.
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.
- Answer-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. -
Answer-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.
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. - Answer-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
