NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review Questions, Med Surg
Exam 3 Burns Questions, Med Surg : Chapter 25 Burns
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.
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 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. - ANSWER 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. - 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.
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. - ANSWER 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?
Exam 3 Burns Questions, Med Surg : Chapter 25 Burns
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.
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 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. - ANSWER 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. - 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.
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. - ANSWER 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?
