BURNS NCLEX QUESTION AND BURN
INJURY NURSING MANAGEMENT
(PART 5: 20 ITEMS)
1. Question
In assessing the client’s potential for an inhalation injury as a
result of a flame burn, what is the most important question to
ask the client on admission?
o A. “Are you a smoker?”
o B. “When was your last chest x-ray?”
o C. “Have you ever had asthma or any other lung
problem?”
o D. “In what exact place or space were you when
you were burned?”
Correct Answer: D. “In what exact place or space were
you when you were burned?”
The risk for inhalation injury is greatest when flame burns occur
indoors in small, poorly ventilated rooms. The composition of
smoke varies with each fire depending upon the materials being
burned, the amount of oxygen available to the fire, and the
nature of the fire. It is important to elucidate whether the
exposure was to smoke, flames, and/or possible chemicals (both
industrial and household). Duration of exposure, the location of
exposure (such as if it was in an enclosed space), and any loss of
consciousness are all important as well.
Option A: Although smoking increases the risk for
some problems, it does not predispose the client for
an inhalation injury. History-taking should be complete
and thorough. Burn patients may have extensive
external injuries, but smoke inhalation may affect
those with no outward signs of burns.
Option B: Workup of smoke inhalation injury may
include serial chest radiographs (often negative early
in smoke inhalation injury) and computed tomography
, (CT) chest. A delay in the onset of symptoms is not
uncommon, and clinicians should educate patients on
the possibility of delayed symptom onset post-
exposure. The delayed symptoms occur in the lower
respiratory airways as it is caused by chemical toxin
exposure, which may bypass the upper airways.
Option C: Short-term complications are seen in more
severe injuries within 4 to 5 days, and the most
common issue is pneumonia. Acute respiratory
distress syndrome and pulmonary edema are also
seen in the short term.
2. 2. Question
Which information obtained by assessment ensures that the
client’s respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited.
Correct Answer: C. The client’s oxygen saturation is 97%.
Clients may have ineffective respiratory efforts and gas exchange
even though they are able to talk, have good respiratory
movement, and are alert. The best indicator for respiratory
effectiveness is the maintenance of oxygen saturation within the
normal range.
Option A: A thorough respiratory assessment consists
of inspection, palpation, percussion, and auscultation
in conjunction with a comprehensive health history.
Use a systematic approach and compare findings
between left and right so the patient serves as his own
control.
Option B: Respirations should be even, unlabored,
and regular at a rate of 12 to 20 breaths per minute.
Normally, inspiration is half as long as expiration, and
chest expansion is symmetrical. If the client appears
anxious or exhibits nasal flaring, cyanosis of the lips
, and mouth, intercostal retraction, or use of accessory
muscles of respiration, he may be in respiratory
distress.
Option D: Normally, the thorax is symmetrical and
the anterior-posterior diameter is less than the
transverse diameter. (Equal diameters may signal
chronic obstructive pulmonary disease in an adult.)
Note any structural deformity such as a pigeon chest
(pectus carinatum) or funnel chest (pectus
excavatum).
3. 3. Question
The nursing instructor is going over burn injuries. The instructor
tells the students that the nursing care priorities for a patient
with a burn injury include wound care, nutritional support, and
prevention of complications such as infection. Based upon these
care priorities, the instructor is most likely discussing a patient
in what phase of burn care?
A. Emergent Phase
B. Immediate Resuscitative Phase
C. Acute Phase
D. Rehabilitation Phase
Correct Answer: C. Acute Phase
The acute or intermediate phase of burn care follows the
emergent/resuscitative phase and begins 48 to 72 hours after the
burn injury. During this phase, attention is directed toward
continued assessment and maintenance of respiratory and
circulatory status, fluid and electrolyte balance, and
gastrointestinal function. Infection prevention, burn wound care
that includes wound cleaning, topical antibacterial therapy,
wound dressing, dressing changes, wound debridement, and
wound grafting, pain management, and nutritional support are
priorities at this stage and are discussed in detail in the following
sections.
Option A: The emergent phase begins with the onset
of burn injury and lasts until the completion of fluid
INJURY NURSING MANAGEMENT
(PART 5: 20 ITEMS)
1. Question
In assessing the client’s potential for an inhalation injury as a
result of a flame burn, what is the most important question to
ask the client on admission?
o A. “Are you a smoker?”
o B. “When was your last chest x-ray?”
o C. “Have you ever had asthma or any other lung
problem?”
o D. “In what exact place or space were you when
you were burned?”
Correct Answer: D. “In what exact place or space were
you when you were burned?”
The risk for inhalation injury is greatest when flame burns occur
indoors in small, poorly ventilated rooms. The composition of
smoke varies with each fire depending upon the materials being
burned, the amount of oxygen available to the fire, and the
nature of the fire. It is important to elucidate whether the
exposure was to smoke, flames, and/or possible chemicals (both
industrial and household). Duration of exposure, the location of
exposure (such as if it was in an enclosed space), and any loss of
consciousness are all important as well.
Option A: Although smoking increases the risk for
some problems, it does not predispose the client for
an inhalation injury. History-taking should be complete
and thorough. Burn patients may have extensive
external injuries, but smoke inhalation may affect
those with no outward signs of burns.
Option B: Workup of smoke inhalation injury may
include serial chest radiographs (often negative early
in smoke inhalation injury) and computed tomography
, (CT) chest. A delay in the onset of symptoms is not
uncommon, and clinicians should educate patients on
the possibility of delayed symptom onset post-
exposure. The delayed symptoms occur in the lower
respiratory airways as it is caused by chemical toxin
exposure, which may bypass the upper airways.
Option C: Short-term complications are seen in more
severe injuries within 4 to 5 days, and the most
common issue is pneumonia. Acute respiratory
distress syndrome and pulmonary edema are also
seen in the short term.
2. 2. Question
Which information obtained by assessment ensures that the
client’s respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited.
Correct Answer: C. The client’s oxygen saturation is 97%.
Clients may have ineffective respiratory efforts and gas exchange
even though they are able to talk, have good respiratory
movement, and are alert. The best indicator for respiratory
effectiveness is the maintenance of oxygen saturation within the
normal range.
Option A: A thorough respiratory assessment consists
of inspection, palpation, percussion, and auscultation
in conjunction with a comprehensive health history.
Use a systematic approach and compare findings
between left and right so the patient serves as his own
control.
Option B: Respirations should be even, unlabored,
and regular at a rate of 12 to 20 breaths per minute.
Normally, inspiration is half as long as expiration, and
chest expansion is symmetrical. If the client appears
anxious or exhibits nasal flaring, cyanosis of the lips
, and mouth, intercostal retraction, or use of accessory
muscles of respiration, he may be in respiratory
distress.
Option D: Normally, the thorax is symmetrical and
the anterior-posterior diameter is less than the
transverse diameter. (Equal diameters may signal
chronic obstructive pulmonary disease in an adult.)
Note any structural deformity such as a pigeon chest
(pectus carinatum) or funnel chest (pectus
excavatum).
3. 3. Question
The nursing instructor is going over burn injuries. The instructor
tells the students that the nursing care priorities for a patient
with a burn injury include wound care, nutritional support, and
prevention of complications such as infection. Based upon these
care priorities, the instructor is most likely discussing a patient
in what phase of burn care?
A. Emergent Phase
B. Immediate Resuscitative Phase
C. Acute Phase
D. Rehabilitation Phase
Correct Answer: C. Acute Phase
The acute or intermediate phase of burn care follows the
emergent/resuscitative phase and begins 48 to 72 hours after the
burn injury. During this phase, attention is directed toward
continued assessment and maintenance of respiratory and
circulatory status, fluid and electrolyte balance, and
gastrointestinal function. Infection prevention, burn wound care
that includes wound cleaning, topical antibacterial therapy,
wound dressing, dressing changes, wound debridement, and
wound grafting, pain management, and nutritional support are
priorities at this stage and are discussed in detail in the following
sections.
Option A: The emergent phase begins with the onset
of burn injury and lasts until the completion of fluid
