lOMoARcPSD|3920845
Burn NCLEX Questions with Answers and Rationales
1. A nurse is caring for a client who has full-thickness burns covering 63% of her body
and smoke inhalation. Which of the following nursing actions is top priority?
A. Monitor intake and output
B. Administer antibiotics
C. Monitor respiratory status
D. Encourage fluid and food intake
Correct Answer is C. Monitor Respiratory Status
The priority action for the nurse when using airway, breathing, and circulation (ABC)
approach to client care is to monitor the client’s respiratory status closely. Smoke
inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from
the inflammatory response to heat can obstruct the airway. Endotracheal intubation may
become necessary to maintain a patient airway.
Incorrect Answers
A. The nurse should monitor the client’s intake and output because clients who have
sustained major burns quickly dehydrate as a result of the fluid shift from the
vascular system into the interstitial space; however, another action is the priority.
B. Infection is serious health risk for clients who sustained major burns, and antibiotic
therapy is probable; however, another action is the priority.
C. Nutritional support is essential for clients who sustained major burns, although they
might receive nutrients via IV or enteral tube initially; another action is the priority
, lOMoARcPSD|3920845
2. A nurse is planning care for a client who has deep partial-thickness and full-thickness
thermal burns over 40% of his total body surface and is in the acute phase of burn
injury. Which of the following interventions should the nurse include in the plan?
A. Initiate range of motion exercises
B. Use clean technique to provide wound care
C. Place the client on low protein diet
D. Maintain the client on bed rest
Correct Answer: A. Initiate range of motion exercises
The nurse should begin performing active and passive range of motion exercises with the
client to maintain mobility and prevent contractures.
Incorrect Answers:
B. The nurse should use sterile technique to provide wound care for this client to
reduce the risk of infection.
C. The nurse should place the client on a high-protein, high-calorie diet to
promote wound healing.
D. The nurse should encourage the client to ambulate frequently to promote mobility
and improve ventilation.
3. A nurse is caring for an adolescent client who has burn wounds on her face and hands.
Which of the following statements by the client indicates that she has adapted to her
changed body image?
A. “May I go with my family to visitor’s lounge?”
, lOMoARcPSD|3920845
B. “I’ll see my friends when I get home”
C. “My dad is coming to visit me. Can you fix my hair for me?”
D. “I told my cousins I’m in protective custody.”
Correct Answer: A. “May I go with my family to the
lounge?” Incorrect Answers:
B. This statement indicates that the client does not feel comfortable being seen by
her peer group. Since peer interaction is important to an adolescent, the client's
statement shows that she has not accepted the alterations in her face and hands.
C. Asking for assistance with her appearance indicates the client has not yet accepted or
adapted to her changed body image. Encouraging the client’s participation in self-care
activities is a suggested nursing intervention because the independence fosters self-
worth and a positive self-image.
D. This statement indicates that the client does not feel comfortable being seen by
her extended family. It demonstrates an attempt to escape from interpersonal contact
and indicates that the client has not accepted the alterations in her face and hands.
4. A nurse is evaluating the laboratory values of a client who is in the resuscitation phase
following a major burn. Which of the following laboratory findings should the nurse
expect?
A. Hemoglobin 10 g/dL
B. Sodium 132 mEq/L
C. Albumin 3.6 g/dL
D. Potassium 4.0 mEq/dL
, lOMoARcPSD|3920845
Correct Answer: B. Sodium 132 mEq/L
This laboratory finding is below the expected reference range. The nurse
should anticipate a low sodium level because sodium is trapped in interstitial
space.
Incorrect Answer:
A. This laboratory value is below the expected reference range. The nurse should
anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of
fluid volume.
C. This laboratory finding is within the expected reference range. The nurse should
anticipate a low albumin level during the resuscitation phase.
D. This laboratory finding is within the expected reference range. The nurse should
anticipate an elevated potassium level during the resuscitation phase.
5. A nurse is caring for a client who has burn injuries on his trunk. The nurse is
explaining what to expect from the prescribed hydrotherapy. Which of the following
statements by the client indicates an understanding of the teaching?
A. “I will be on a special shower table.”
B. “The water temperature will be very cool to ease my pain.”
C. “The nurse will use a firm-bristled brush to remove loose skin.”
D. “The nurse will use scissors to open small blisters.”
Correct Answer: A. "I will be on a special shower table."
The special shower table facilitates examination and debridement of the wound during
hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is
that the water can be kept at a constant temperature; there is also a lower risk of wound
infection.
Burn NCLEX Questions with Answers and Rationales
1. A nurse is caring for a client who has full-thickness burns covering 63% of her body
and smoke inhalation. Which of the following nursing actions is top priority?
A. Monitor intake and output
B. Administer antibiotics
C. Monitor respiratory status
D. Encourage fluid and food intake
Correct Answer is C. Monitor Respiratory Status
The priority action for the nurse when using airway, breathing, and circulation (ABC)
approach to client care is to monitor the client’s respiratory status closely. Smoke
inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from
the inflammatory response to heat can obstruct the airway. Endotracheal intubation may
become necessary to maintain a patient airway.
Incorrect Answers
A. The nurse should monitor the client’s intake and output because clients who have
sustained major burns quickly dehydrate as a result of the fluid shift from the
vascular system into the interstitial space; however, another action is the priority.
B. Infection is serious health risk for clients who sustained major burns, and antibiotic
therapy is probable; however, another action is the priority.
C. Nutritional support is essential for clients who sustained major burns, although they
might receive nutrients via IV or enteral tube initially; another action is the priority
, lOMoARcPSD|3920845
2. A nurse is planning care for a client who has deep partial-thickness and full-thickness
thermal burns over 40% of his total body surface and is in the acute phase of burn
injury. Which of the following interventions should the nurse include in the plan?
A. Initiate range of motion exercises
B. Use clean technique to provide wound care
C. Place the client on low protein diet
D. Maintain the client on bed rest
Correct Answer: A. Initiate range of motion exercises
The nurse should begin performing active and passive range of motion exercises with the
client to maintain mobility and prevent contractures.
Incorrect Answers:
B. The nurse should use sterile technique to provide wound care for this client to
reduce the risk of infection.
C. The nurse should place the client on a high-protein, high-calorie diet to
promote wound healing.
D. The nurse should encourage the client to ambulate frequently to promote mobility
and improve ventilation.
3. A nurse is caring for an adolescent client who has burn wounds on her face and hands.
Which of the following statements by the client indicates that she has adapted to her
changed body image?
A. “May I go with my family to visitor’s lounge?”
, lOMoARcPSD|3920845
B. “I’ll see my friends when I get home”
C. “My dad is coming to visit me. Can you fix my hair for me?”
D. “I told my cousins I’m in protective custody.”
Correct Answer: A. “May I go with my family to the
lounge?” Incorrect Answers:
B. This statement indicates that the client does not feel comfortable being seen by
her peer group. Since peer interaction is important to an adolescent, the client's
statement shows that she has not accepted the alterations in her face and hands.
C. Asking for assistance with her appearance indicates the client has not yet accepted or
adapted to her changed body image. Encouraging the client’s participation in self-care
activities is a suggested nursing intervention because the independence fosters self-
worth and a positive self-image.
D. This statement indicates that the client does not feel comfortable being seen by
her extended family. It demonstrates an attempt to escape from interpersonal contact
and indicates that the client has not accepted the alterations in her face and hands.
4. A nurse is evaluating the laboratory values of a client who is in the resuscitation phase
following a major burn. Which of the following laboratory findings should the nurse
expect?
A. Hemoglobin 10 g/dL
B. Sodium 132 mEq/L
C. Albumin 3.6 g/dL
D. Potassium 4.0 mEq/dL
, lOMoARcPSD|3920845
Correct Answer: B. Sodium 132 mEq/L
This laboratory finding is below the expected reference range. The nurse
should anticipate a low sodium level because sodium is trapped in interstitial
space.
Incorrect Answer:
A. This laboratory value is below the expected reference range. The nurse should
anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of
fluid volume.
C. This laboratory finding is within the expected reference range. The nurse should
anticipate a low albumin level during the resuscitation phase.
D. This laboratory finding is within the expected reference range. The nurse should
anticipate an elevated potassium level during the resuscitation phase.
5. A nurse is caring for a client who has burn injuries on his trunk. The nurse is
explaining what to expect from the prescribed hydrotherapy. Which of the following
statements by the client indicates an understanding of the teaching?
A. “I will be on a special shower table.”
B. “The water temperature will be very cool to ease my pain.”
C. “The nurse will use a firm-bristled brush to remove loose skin.”
D. “The nurse will use scissors to open small blisters.”
Correct Answer: A. "I will be on a special shower table."
The special shower table facilitates examination and debridement of the wound during
hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is
that the water can be kept at a constant temperature; there is also a lower risk of wound
infection.
