NCLEX Emergency/Burns/Triage
Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A patient arrives with airway swelling after a burn injury. What is the nurse’s priority?
✔✔A. Maintain a patent airway
B. Apply sterile dressings
C. Administer pain medication
D. Start IV fluids
Which patient should be triaged first in the emergency department?
A. Stable patient with ankle sprain
B. Patient with mild abdominal pain
✔✔C. Patient with chest pain and shortness of breath
D. Patient requesting medication refill
A client with facial burns is at highest risk for which complication?
✔✔A. Airway obstruction
B. Dehydration
C. Infection
D. Hypothermia
Which burn affects only the epidermis?
1
,✔✔A. First-degree burn
B. Second-degree burn
C. Third-degree burn
D. Full-thickness burn
A patient with burns covering 40% of the body is at highest risk for:
A. Hypertension
✔✔B. Fluid volume deficit
C. Hypoglycemia
D. Bradycardia
Which finding indicates inhalation injury?
A. Cool skin
B. Blistered feet
✔✔C. Soot around the mouth
D. Pale nail beds
Which patient should be seen first using triage principles?
✔✔A. Unconscious patient with shallow breathing
B. Patient with controlled bleeding
C. Patient with nausea and vomiting
D. Patient with mild headache
2
,What is the best initial action for a chemical burn to the eye?
A. Apply antibiotic ointment
✔✔B. Irrigate with copious water
C. Cover with dry dressing
D. Apply ice
Which burn is described as red, painful, and without blisters?
✔✔A. First-degree burn
B. Second-degree burn
C. Third-degree burn
D. Electrical burn
A burn patient suddenly develops restlessness and confusion. What does this most likely
indicate?
A. Pain
✔✔B. Hypoxia
C. Infection
D. Dehydration
Which patient should the triage nurse classify as emergent?
A. Stable fracture
✔✔B. Severe shortness of breath
C. Minor laceration
3
, D. Chronic back pain
What is the priority nursing action during the emergent phase of burn care?
✔✔A. Fluid resuscitation
B. Nutritional support
C. Wound debridement
D. Physical therapy
Which burn injury is most likely to cause cardiac arrhythmias?
A. Thermal burn
B. Chemical burn
✔✔C. Electrical burn
D. Radiation burn
A client has a partial-thickness burn. Which finding is expected?
A. White, leathery skin
✔✔B. Blisters and pain
C. No sensation
D. Dry, brown skin
Which patient can safely wait the longest for treatment?
A. Patient with head injury
B. Patient with chest pain
4
Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A patient arrives with airway swelling after a burn injury. What is the nurse’s priority?
✔✔A. Maintain a patent airway
B. Apply sterile dressings
C. Administer pain medication
D. Start IV fluids
Which patient should be triaged first in the emergency department?
A. Stable patient with ankle sprain
B. Patient with mild abdominal pain
✔✔C. Patient with chest pain and shortness of breath
D. Patient requesting medication refill
A client with facial burns is at highest risk for which complication?
✔✔A. Airway obstruction
B. Dehydration
C. Infection
D. Hypothermia
Which burn affects only the epidermis?
1
,✔✔A. First-degree burn
B. Second-degree burn
C. Third-degree burn
D. Full-thickness burn
A patient with burns covering 40% of the body is at highest risk for:
A. Hypertension
✔✔B. Fluid volume deficit
C. Hypoglycemia
D. Bradycardia
Which finding indicates inhalation injury?
A. Cool skin
B. Blistered feet
✔✔C. Soot around the mouth
D. Pale nail beds
Which patient should be seen first using triage principles?
✔✔A. Unconscious patient with shallow breathing
B. Patient with controlled bleeding
C. Patient with nausea and vomiting
D. Patient with mild headache
2
,What is the best initial action for a chemical burn to the eye?
A. Apply antibiotic ointment
✔✔B. Irrigate with copious water
C. Cover with dry dressing
D. Apply ice
Which burn is described as red, painful, and without blisters?
✔✔A. First-degree burn
B. Second-degree burn
C. Third-degree burn
D. Electrical burn
A burn patient suddenly develops restlessness and confusion. What does this most likely
indicate?
A. Pain
✔✔B. Hypoxia
C. Infection
D. Dehydration
Which patient should the triage nurse classify as emergent?
A. Stable fracture
✔✔B. Severe shortness of breath
C. Minor laceration
3
, D. Chronic back pain
What is the priority nursing action during the emergent phase of burn care?
✔✔A. Fluid resuscitation
B. Nutritional support
C. Wound debridement
D. Physical therapy
Which burn injury is most likely to cause cardiac arrhythmias?
A. Thermal burn
B. Chemical burn
✔✔C. Electrical burn
D. Radiation burn
A client has a partial-thickness burn. Which finding is expected?
A. White, leathery skin
✔✔B. Blisters and pain
C. No sensation
D. Dry, brown skin
Which patient can safely wait the longest for treatment?
A. Patient with head injury
B. Patient with chest pain
4
