1
Burns and Burn Injury Management Nursing Test
Banks
Burns NCLEX Questions & Reviewer (100 Items)
ER
Burn Injury Nursing Management NCLEX Challenge Exam (Quiz #1: 20 Questions)
GH
I
1. Question1 point(s)
A 23-year-old male client who has had a full-thickness burn is being discharged from the
H
hospital. Which information is most important for the nurse to provide prior to discharge?
G
A. How to maintain home smoke detectors
N
B. Joining a community reintegration program
I
C. Learning to perform dressing changes
Y
D. Options available for scar removal
L
Correct
F
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.
, 2
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.
R
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
E
“improve both the function and the cosmetic appearance of burn scars”.
2. Question1 point(s)
H
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
G
find pedal pulses. Which action will the nurse take first?
HI
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
G
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
IN
.
Correct Answer: A. Start intravenous fluids.
LY
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious
F
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.
, 3
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. Question1 point(s)
A 40-year-old male client who was burned was admitted under your care. Assessment reveals
R
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
HE
B. Perform chest physiotherapy
G
C. Monitor urine output
I
D. Place the client in an upright position
H
.
Correct Answer: D. Place the client in an upright position
NG
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur
I
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.
LY
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.
F
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. Question1 point(s)
How will the nurse position a client with a burn wound to the posterior neck to prevent
contractures?
, 4
A. Have the client turn the head from side to side.
B. Keep the client in a supine position without the use of pillows.
C. Keep the client in a semi-Fowler's position with her or his arms elevated.
R
D. Place a towel roll under the client's neck or shoulder.
E
.
Correct Answer: A. Have the client turn the head from side to side.
GH
Deformities and contractures can often be prevented by proper positioning. Maintaining proper
I
body alignment when the patient is in bed is vital. The function that would be disrupted by a
contracture to the posterior neck is flexion. Moving the head from side to side prevents such a
loss of flexion. This movement is what would prevent contractures from occurring.
GH
Option B: The client should not only be in a supine position but there should be a movement to
avoid contractures. Splinting and proper positioning will also help achieve the prevention of
contractures. As a matter of importance, movement should be incorporated into the patient’s
N
daily routine from their inception to the hospital.
I
Option C: The burns are in the client’s posterior neck. Performing active or passive range of
motion (ROM) exercises, depending on the patient’s level of consciousness is crucial in the
Y
prevention of these complications.
L
Option D: Placing a towel roll under the neck might not help prevent contractures.
Immobilization is only allowed when a part of the body has just been grafted. Even then, the
F
area must be kept in an antideformity position.
5. Question1 point(s)
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing.
Several hours later, the wheezing is no longer heard. What is the nurse’s next action?
A. Documenting the findings
B. Loosening any dressings on the chest
Burns and Burn Injury Management Nursing Test
Banks
Burns NCLEX Questions & Reviewer (100 Items)
ER
Burn Injury Nursing Management NCLEX Challenge Exam (Quiz #1: 20 Questions)
GH
I
1. Question1 point(s)
A 23-year-old male client who has had a full-thickness burn is being discharged from the
H
hospital. Which information is most important for the nurse to provide prior to discharge?
G
A. How to maintain home smoke detectors
N
B. Joining a community reintegration program
I
C. Learning to perform dressing changes
Y
D. Options available for scar removal
L
Correct
F
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.
, 2
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.
R
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
E
“improve both the function and the cosmetic appearance of burn scars”.
2. Question1 point(s)
H
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
G
find pedal pulses. Which action will the nurse take first?
HI
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
G
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
IN
.
Correct Answer: A. Start intravenous fluids.
LY
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious
F
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.
, 3
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. Question1 point(s)
A 40-year-old male client who was burned was admitted under your care. Assessment reveals
R
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
HE
B. Perform chest physiotherapy
G
C. Monitor urine output
I
D. Place the client in an upright position
H
.
Correct Answer: D. Place the client in an upright position
NG
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur
I
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.
LY
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.
F
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. Question1 point(s)
How will the nurse position a client with a burn wound to the posterior neck to prevent
contractures?
, 4
A. Have the client turn the head from side to side.
B. Keep the client in a supine position without the use of pillows.
C. Keep the client in a semi-Fowler's position with her or his arms elevated.
R
D. Place a towel roll under the client's neck or shoulder.
E
.
Correct Answer: A. Have the client turn the head from side to side.
GH
Deformities and contractures can often be prevented by proper positioning. Maintaining proper
I
body alignment when the patient is in bed is vital. The function that would be disrupted by a
contracture to the posterior neck is flexion. Moving the head from side to side prevents such a
loss of flexion. This movement is what would prevent contractures from occurring.
GH
Option B: The client should not only be in a supine position but there should be a movement to
avoid contractures. Splinting and proper positioning will also help achieve the prevention of
contractures. As a matter of importance, movement should be incorporated into the patient’s
N
daily routine from their inception to the hospital.
I
Option C: The burns are in the client’s posterior neck. Performing active or passive range of
motion (ROM) exercises, depending on the patient’s level of consciousness is crucial in the
Y
prevention of these complications.
L
Option D: Placing a towel roll under the neck might not help prevent contractures.
Immobilization is only allowed when a part of the body has just been grafted. Even then, the
F
area must be kept in an antideformity position.
5. Question1 point(s)
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing.
Several hours later, the wheezing is no longer heard. What is the nurse’s next action?
A. Documenting the findings
B. Loosening any dressings on the chest
