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Burns, Wound Care & Skin Integrity NCLEX Q&A
(Saunders 9th Ed Chapter 43) | 2025–2026 NGN
Practice Questions + A+ Verified Rationales
Question 1 (SATA)
A nurse is assessing a client with partial-thickness burns on both arms. Which
findings are expected in this type of burn? (Select all that apply.)
A. Blister formation
B. Intact epidermis with redness only
C. Severe pain
D. Moist wound surface
E. Eschar formation
Correct Answers: A, C, D
Rationale:
Partial-thickness (second-degree) burns involve the epidermis and part of the
, 2
dermis, presenting as red, blistered, moist, and very painful wounds. Eschar
forms in full-thickness burns, and intact epidermis with redness only describes
first-degree burns.
Question 2 (SATA)
A client sustains thermal burns covering 30% of total body surface area
(TBSA). Which initial nursing interventions are priority? (Select all that apply.)
A. Establish a patent airway
B. Initiate IV fluid resuscitation
C. Administer IV opioids for pain
D. Start oral fluid intake immediately
E. Maintain urine output of 30–50 mL/hr
Correct Answers: A, B, C, E
Rationale:
Acute burn management (emergent phase) prioritizes airway, breathing, and
circulation, including airway protection, IV fluid resuscitation, IV pain
management, and urine output monitoring. Oral intake is avoided initially to
prevent aspiration and ensure accurate fluid management.
, 3
Question 3 (SATA)
The nurse is teaching a burn client about infection prevention. Which
instructions are correct? (Select all that apply.)
A. Perform hand hygiene before wound care
B. Use sterile gloves during dressing changes
C. Avoid fresh flowers or plants in the room
D. Limit visitors with active infections
E. Apply topical antibiotics directly with bare hands
Correct Answers: A, B, C, D
Rationale:
Burn clients are highly susceptible to infection due to skin barrier loss. Strict
hand hygiene, sterile dressing technique, and environmental controls like
limiting infected visitors and removing plants are key. Bare-hand application of
medications is unsafe.
Question 4 (SATA)
, 4
A client with circumferential full-thickness burn on the leg is at risk for
compartment syndrome. Which findings indicate this complication? (Select all
that apply.)
A. Numbness or tingling in the leg
B. Weak distal pulses
C. Increasing pain despite analgesics
D. Blisters with serous fluid
E. Delayed capillary refill
Correct Answers: A, B, C, E
Rationale:
Compartment syndrome is caused by increased pressure in the limb, leading to
pain, paresthesia, weak pulses, and poor capillary refill. Blistering is typical of
partial-thickness burns, not compartment syndrome.
Question 5 (SATA)
A nurse is preparing to apply silver sulfadiazine cream to a burn wound. Which
actions are correct? (Select all that apply.)
Burns, Wound Care & Skin Integrity NCLEX Q&A
(Saunders 9th Ed Chapter 43) | 2025–2026 NGN
Practice Questions + A+ Verified Rationales
Question 1 (SATA)
A nurse is assessing a client with partial-thickness burns on both arms. Which
findings are expected in this type of burn? (Select all that apply.)
A. Blister formation
B. Intact epidermis with redness only
C. Severe pain
D. Moist wound surface
E. Eschar formation
Correct Answers: A, C, D
Rationale:
Partial-thickness (second-degree) burns involve the epidermis and part of the
, 2
dermis, presenting as red, blistered, moist, and very painful wounds. Eschar
forms in full-thickness burns, and intact epidermis with redness only describes
first-degree burns.
Question 2 (SATA)
A client sustains thermal burns covering 30% of total body surface area
(TBSA). Which initial nursing interventions are priority? (Select all that apply.)
A. Establish a patent airway
B. Initiate IV fluid resuscitation
C. Administer IV opioids for pain
D. Start oral fluid intake immediately
E. Maintain urine output of 30–50 mL/hr
Correct Answers: A, B, C, E
Rationale:
Acute burn management (emergent phase) prioritizes airway, breathing, and
circulation, including airway protection, IV fluid resuscitation, IV pain
management, and urine output monitoring. Oral intake is avoided initially to
prevent aspiration and ensure accurate fluid management.
, 3
Question 3 (SATA)
The nurse is teaching a burn client about infection prevention. Which
instructions are correct? (Select all that apply.)
A. Perform hand hygiene before wound care
B. Use sterile gloves during dressing changes
C. Avoid fresh flowers or plants in the room
D. Limit visitors with active infections
E. Apply topical antibiotics directly with bare hands
Correct Answers: A, B, C, D
Rationale:
Burn clients are highly susceptible to infection due to skin barrier loss. Strict
hand hygiene, sterile dressing technique, and environmental controls like
limiting infected visitors and removing plants are key. Bare-hand application of
medications is unsafe.
Question 4 (SATA)
, 4
A client with circumferential full-thickness burn on the leg is at risk for
compartment syndrome. Which findings indicate this complication? (Select all
that apply.)
A. Numbness or tingling in the leg
B. Weak distal pulses
C. Increasing pain despite analgesics
D. Blisters with serous fluid
E. Delayed capillary refill
Correct Answers: A, B, C, E
Rationale:
Compartment syndrome is caused by increased pressure in the limb, leading to
pain, paresthesia, weak pulses, and poor capillary refill. Blistering is typical of
partial-thickness burns, not compartment syndrome.
Question 5 (SATA)
A nurse is preparing to apply silver sulfadiazine cream to a burn wound. Which
actions are correct? (Select all that apply.)
