Burn Nclex Questions with Answers and Rationales PDF

Preview

Summary

Burn NCLEX Questions with Answers and Rationales 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. ...

Description

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

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?”

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

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.

Incorrect Answers: B. The nurse should use warm water during the hydrotherapy treatment to help the client maintain adequate body temperature. C. The nurse should use soft washcloths or gauze to scrub and debride the wounds gently. D. The nurse should leave small blisters intact but open large blisters. 6.

A nurse is assessing a client who sustained superficial partial-thickness and deep partialthickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1 degrees Celsius Correct Answer: D. Temperature of 39.1°C (102.4°F) An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms. Incorrect Answers: A. Significant edema is expected when fluid shifts after a burn injury. B. Superficial partial-thickness and deep partial-thickness burns are painful throughout burn therapy.

C. A urinary output of 30 mL/hr is within the expected reference range. A decrease in urine output is expected with edema and fluid shifts around the fourth day following a major burn injury. 7.

A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? A. Bacterial growth B. Scarring C. Skin graft size D. Pain Correct Answer: A. Bacterial growth Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It and the dressing create a protective barrier between bacteria and the exposed body tissues. This therapy helps prevent infection. Incorrect Answers: B. Topical antimicrobials do not prevent scarring or minimize permanent damage to the integumentary system. C. Topical antimicrobials do not reduce the size of the skin grafts the client requires. D. Opioids, not topical antimicrobials, reduce pain.

8.

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury

B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output Correct Answer: B. Characteristics of the cough and sputum The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse’s priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse’s priority assessment is the client’s cough characteristics. A client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway. Incorrect Answers: A. The nurse should determine the percentage of the client’s total body surface area that is burned to ensure proper care and provide an estimation of prognosis; however, there is another assessment that the nurse should perform first.

C. The nurse should assess the extent of the client’s edema to determine the effects of the injury on the client’s cardiovascular status; however, there is another assessment that the nurse should perform first. D. The nurse should accurately monitor the client’s urine output to assess kidney function; however, there is another assessment that the nurse should perform first. 9.

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN Correct Answer: B. Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine. Incorrect Answers: A. Silver sulfadiazine does not cause an electrolyte imbalance. C. Hyperchloremia and other electrolyte imbalances can be adverse effects of mafenide acetate solution or cream. D. Impaired kidney function is an adverse effect of gentamicin.

10.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? A. Maintain the client in a prone position.

B. Elevate and immobilize the grafted extremity. C. Maintain the grafted extremity in a flat position. D. Keep the grafted extremity covered with a blanket. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site. 11.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? A. Glucose level of 99 mg/dL (5.65 mmol/L) B. Platelet level 300,000 mm3 (300 x 109/L) C. Magnesium level of 1.5 mEq/L (0.75 mmol/L) D. White Blood count of 3000 mm3 (3.0 x 109/L) Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the primary health care provider is notified, and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia.

The other laboratory values are not specific to this medication and are also within normal limits. 12.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? A. Hyperventilation B. Elevated blood pressure C. Local rash at the burn site D. Local pain at the burn site Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

13.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A. "The medication is an antibacterial." B. "The medication will help heal the burn." C. "The medication should be applied directly to the wound." D. "The medication is likely to cause stinging every time it is applied."

Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gramnegative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied. 14.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A. Immediately before swimming B. 5 minutes before exposure to the sun C. Immediately before exposure to the sun D. At least 30 minutes before exposure to the sun Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

15.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. A. Restrict fluids. B. Assess for airway patency. C. Administer oxygen as prescribed. D. Place a cooling blanket on the client. E. Elevate extremities if no fractures are present.

F. Prepare to give oral pain medication as prescribed. Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained, and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury. 16.

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? A. 18% B. 24% C. 36% D. 48%

Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%. 17.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A. Return of distal pulses B. Brisk bleeding from the site C. Decreasing edema formation. D. Formation of granulation tissue Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation controls the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

18.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

19.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? A. Vital Signs

B. Urine output C. Mental status D. Peripheral pulses Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL. 20.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permea...