100 Burn / fluid balance NCLEX
Question with 100% correctly answers
Graded A+
1. The newly admitted client has burns on both legs. The burned areas
appear white and leather-like. No blisters or bleeding are present, and
the client states that he or she has little pain. How should this injury be
categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness
deep D. Full thickness
2. The newly admitted client has a large burned area on the right arm.
The burned area appears red, has blisters, and is very painful. How
should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
3. The burned client newly arrived from an accident scene is prescribed
to receive 4 mg of morphine sulfate by IV push. What is the most
important reason to administer the opioid analgesic to this client by the
intravenous route?
A. The medication will be effective more quickly than if given
intramuscularly.
B. It is less likely to interfere with the client’s breathing and
oxygenation. C. The danger of an overdose during fluid remobilization
is reduced.
D. The client delayed gastric emptying.
,4. Which vitamin deficiency is most likely to be a long-
term consequence of a full-thickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin
D
5. Which client factors should alert the nurse to potential increased
complications with a burn injury?
A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.
6. The burned client is ordered to receive intravenous cimetidine, an H2
histamine blocking agent, during the emergent phase. When the
client’s family asks why this drug is being given, what is the nurse’s
best response?
A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal
bloating.” C. “To decrease hydrochloric acid production in the stomach
and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and
prevent hypovolemic shock.”
7. At what point after a burn injury should the nurse be most alert for
the complication of hypokalemia?
, A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase
8. What clinical manifestation should alert the nurse to possible carbon
monoxide poisoning in a client who experienced a burn injury during a
house fire?
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
9. What clinical manifestation indicates that an escharotomy is needed
on a circumferential extremity burn?
A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the
extremity. C. Capillary refill is slow in the digits and the distal
pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the
extremity.
10. What additional laboratory test should be performed on any African
American client who sustains a serious burn injury?
A. Total protein
B. Tissue type antigens
C. Prostate-specific antigen
D. Hemoglobin S electrophoresis
Question with 100% correctly answers
Graded A+
1. The newly admitted client has burns on both legs. The burned areas
appear white and leather-like. No blisters or bleeding are present, and
the client states that he or she has little pain. How should this injury be
categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness
deep D. Full thickness
2. The newly admitted client has a large burned area on the right arm.
The burned area appears red, has blisters, and is very painful. How
should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
3. The burned client newly arrived from an accident scene is prescribed
to receive 4 mg of morphine sulfate by IV push. What is the most
important reason to administer the opioid analgesic to this client by the
intravenous route?
A. The medication will be effective more quickly than if given
intramuscularly.
B. It is less likely to interfere with the client’s breathing and
oxygenation. C. The danger of an overdose during fluid remobilization
is reduced.
D. The client delayed gastric emptying.
,4. Which vitamin deficiency is most likely to be a long-
term consequence of a full-thickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin
D
5. Which client factors should alert the nurse to potential increased
complications with a burn injury?
A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.
6. The burned client is ordered to receive intravenous cimetidine, an H2
histamine blocking agent, during the emergent phase. When the
client’s family asks why this drug is being given, what is the nurse’s
best response?
A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal
bloating.” C. “To decrease hydrochloric acid production in the stomach
and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and
prevent hypovolemic shock.”
7. At what point after a burn injury should the nurse be most alert for
the complication of hypokalemia?
, A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase
8. What clinical manifestation should alert the nurse to possible carbon
monoxide poisoning in a client who experienced a burn injury during a
house fire?
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
9. What clinical manifestation indicates that an escharotomy is needed
on a circumferential extremity burn?
A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the
extremity. C. Capillary refill is slow in the digits and the distal
pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the
extremity.
10. What additional laboratory test should be performed on any African
American client who sustains a serious burn injury?
A. Total protein
B. Tissue type antigens
C. Prostate-specific antigen
D. Hemoglobin S electrophoresis
