NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
1. 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: 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
2. 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.: ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the micro-
circulation 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.
3. 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.-
, NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
: 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
4. 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: 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.
5. 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.: 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.
6. 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.
, NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
d. Administer multiple vitamins and minerals in the IV solution.: 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.
7. 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.: 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.
8. 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.: 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.
, NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
9. 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.: 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
10. 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?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood: ANS: D
H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn
injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite
11. The nurse is reviewing the medication administration record (MAR) on a
patient with partial-thickness burns. Which medication is best for the nurse to
administer before scheduled wound debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid): ANS: D
Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance
the effects of opioids.
12. A young adult patient who is in the rehabilitation phase after having deep
partial-thickness face and neck burns has a nursing diagnosis of disturbed
body image. Which statement by the patient indicates that the problem is
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
1. 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: 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
2. 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.: ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the micro-
circulation 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.
3. 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.-
, NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
: 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
4. 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: 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.
5. 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.: 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.
6. 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.
, NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
d. Administer multiple vitamins and minerals in the IV solution.: 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.
7. 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.: 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.
8. 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.: 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.
, NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review
Questions, Med Surg Exam 3 Burns Questions, Med Surg : Chapter 25 Bu
Study online at https://quizlet.com/_7d6zwa
9. 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.: 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
10. 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?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood: ANS: D
H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn
injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite
11. The nurse is reviewing the medication administration record (MAR) on a
patient with partial-thickness burns. Which medication is best for the nurse to
administer before scheduled wound debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid): ANS: D
Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance
the effects of opioids.
12. A young adult patient who is in the rehabilitation phase after having deep
partial-thickness face and neck burns has a nursing diagnosis of disturbed
body image. Which statement by the patient indicates that the problem is
