Burns NCLEX Question and Burn
Injury Nursing Management (Part 1:
20 Items)
1. Question
A 23-year-old male client who has had a full-thickness burn is
being discharged from the hospital. Which information is most
important for the nurse to provide prior to discharge?
o A. How to maintain home smoke detectors
o B. Joining a community reintegration program
o C. Learning to perform dressing changes
o D. Options available for scar removal
Correct Answer: C. Learning to perform dressing changes
Teaching the patient and his family to perform dressing changes
is critical for the goal of progression towards independence.
Proper management of burn injury through proper dressing
changes helps prevent wound deterioration. Encouragement of
the patient and his family members in participating in dressing
changes and wound care helps prepare for the patient’s eventual
discharge and home care needs. All other choices (below) are
important during the rehabilitation stage but dressing changes is
a priority.
Option A: Teach on the importance of installing and
maintaining smoke detectors on every level of the
home and changing batteries periodically to help
prevent fires.
Option B: Surviving a burn injury has a tremendous
psychological impact on the patient and family. The
nurse plays a key role in helping the patient adapt.
Providing referrals to social services and counseling
helps the patient during his rehabilitation phase.
Option D: Discussion about burn reconstruction
treatment after the scars have healed or matured is
usually discussed after the first few years after injury.
, This option is often used to “improve both the function
and the cosmetic appearance of burn scars”.
2. 2. Question
A client who is admitted after a thermal burn injury has the
following vital signs: blood pressure, 70/40; heart rate, 140
beats/min; respiratory rate, 25/min. He is pale in color and it is
difficult to find pedal pulses. Which action will the nurse
take first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
Correct Answer: A. Start intravenous fluids.
Hypovolemic shock is a common cause of death in the emergent
phase of clients with serious injuries. Administration of fluids can
treat this problem. For burns classified as severe (> 20% TBSA),
fluid resuscitation should be initiated to maintain urine output >
0.5 mL/kg/hour.
Option C: Following a severe burn injury, significant
hematologic changes occur that are reflected in
complete blood count (CBC) measurements. A CBC will
be taken to ascertain if a cardiac or bleeding problem
is causing these vital signs. However, these are not
actions that the nurse would take immediately.
Option B: Checking pulses would indicate perfusion
to the periphery but this is not an immediate nursing
action. Carefully check pulses in any extremity with
circumferential burns. These burns can act as
tourniquets as burn-associated edema begins, leading
to compartment syndrome.
Option D: In patients with extensive burns, it is
sometimes a challenge to monitor the ECG, because
the lack of natural skin and application of protective
ointments prevent the adherence of the ECG discs.
3. 3. Question
, A 40-year-old male client who was burned was admitted under
your care. Assessment reveals he has crackles, respiratory rate of
40/min, and is coughing up blood-tinged sputum. What action will
the nurse take first?
A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position
Correct Answer: D. Place the client in an upright position
Pulmonary edema can result from fluid resuscitation given for
burn treatment. This can occur even in a young healthy person.
Placing the client in an upright position can relieve lung
congestion immediately before other measures can be carried
out.
Option A: Digoxin may be given later to increase
cardiac contractility to prevent backup of fluid into the
lungs. However, digoxin has the potential to cause
bradyarrhythmias.
Option B: Chest physiotherapy will not get rid of the
fluid and is not a priority among the choices. Chest
physiotherapy is only applicable during the post-burn
management of the patient.
Option C: Monitoring urine output is important.
However, it is not an immediate intervention. Use the
patient’s urine output and physiologic response to
determine if the volume is adequate for resuscitation.
4. 4. Question
How will the nurse position a client with a burn wound to the
posterior neck to prevent contractures?
A. Have the client turn the head from side to side.
B. Keep the client in a supine position without the use of
pillows.
Injury Nursing Management (Part 1:
20 Items)
1. Question
A 23-year-old male client who has had a full-thickness burn is
being discharged from the hospital. Which information is most
important for the nurse to provide prior to discharge?
o A. How to maintain home smoke detectors
o B. Joining a community reintegration program
o C. Learning to perform dressing changes
o D. Options available for scar removal
Correct Answer: C. Learning to perform dressing changes
Teaching the patient and his family to perform dressing changes
is critical for the goal of progression towards independence.
Proper management of burn injury through proper dressing
changes helps prevent wound deterioration. Encouragement of
the patient and his family members in participating in dressing
changes and wound care helps prepare for the patient’s eventual
discharge and home care needs. All other choices (below) are
important during the rehabilitation stage but dressing changes is
a priority.
Option A: Teach on the importance of installing and
maintaining smoke detectors on every level of the
home and changing batteries periodically to help
prevent fires.
Option B: Surviving a burn injury has a tremendous
psychological impact on the patient and family. The
nurse plays a key role in helping the patient adapt.
Providing referrals to social services and counseling
helps the patient during his rehabilitation phase.
Option D: Discussion about burn reconstruction
treatment after the scars have healed or matured is
usually discussed after the first few years after injury.
, This option is often used to “improve both the function
and the cosmetic appearance of burn scars”.
2. 2. Question
A client who is admitted after a thermal burn injury has the
following vital signs: blood pressure, 70/40; heart rate, 140
beats/min; respiratory rate, 25/min. He is pale in color and it is
difficult to find pedal pulses. Which action will the nurse
take first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
Correct Answer: A. Start intravenous fluids.
Hypovolemic shock is a common cause of death in the emergent
phase of clients with serious injuries. Administration of fluids can
treat this problem. For burns classified as severe (> 20% TBSA),
fluid resuscitation should be initiated to maintain urine output >
0.5 mL/kg/hour.
Option C: Following a severe burn injury, significant
hematologic changes occur that are reflected in
complete blood count (CBC) measurements. A CBC will
be taken to ascertain if a cardiac or bleeding problem
is causing these vital signs. However, these are not
actions that the nurse would take immediately.
Option B: Checking pulses would indicate perfusion
to the periphery but this is not an immediate nursing
action. Carefully check pulses in any extremity with
circumferential burns. These burns can act as
tourniquets as burn-associated edema begins, leading
to compartment syndrome.
Option D: In patients with extensive burns, it is
sometimes a challenge to monitor the ECG, because
the lack of natural skin and application of protective
ointments prevent the adherence of the ECG discs.
3. 3. Question
, A 40-year-old male client who was burned was admitted under
your care. Assessment reveals he has crackles, respiratory rate of
40/min, and is coughing up blood-tinged sputum. What action will
the nurse take first?
A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position
Correct Answer: D. Place the client in an upright position
Pulmonary edema can result from fluid resuscitation given for
burn treatment. This can occur even in a young healthy person.
Placing the client in an upright position can relieve lung
congestion immediately before other measures can be carried
out.
Option A: Digoxin may be given later to increase
cardiac contractility to prevent backup of fluid into the
lungs. However, digoxin has the potential to cause
bradyarrhythmias.
Option B: Chest physiotherapy will not get rid of the
fluid and is not a priority among the choices. Chest
physiotherapy is only applicable during the post-burn
management of the patient.
Option C: Monitoring urine output is important.
However, it is not an immediate intervention. Use the
patient’s urine output and physiologic response to
determine if the volume is adequate for resuscitation.
4. 4. Question
How will the nurse position a client with a burn wound to the
posterior neck to prevent contractures?
A. Have the client turn the head from side to side.
B. Keep the client in a supine position without the use of
pillows.
