39 terms

NCLEX Style Practice Questions Burns

A patient comes into the emergency department with a chemical burn from contact with lye.Assessment and treatment of this patient will be based on what knowledge regarding this type of burn? (Select all that apply)
1. This is an alkali burn.
2. This type of burn tends to be deeper.
3. This is an acid burn.
4. This type of burn will be easier to neutralize.
5. This type of burn tends to be more superficial.
Correct Answer: 1,2
Rationale: This is an alkali burn which is more difficult to neutralize than an acid burn and tends to have a deeper penetration and be more severe than a burn caused by an acid.
A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply.
1. What type of current was involved?
2. How long was the patient in contact with the current?
3. How much voltage was involved?
4. Where was the patient when the burn occurred?
5. What was the point of contact with the current?
Correct Answer: 1,2,3
Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity.
A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse?
1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the patient to prevent heat loss.
4. Move the patient indoors to a dry place.
5. Get the patient up off the ground.
Correct Answer: 1
Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. All other actions are secondary.
A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in these instructions?
(Select all that apply)
1. drain cleaners
2. household ammonia
3. oven cleaner
4. toiler bowl cleaner
5. lemon oil furniture polish
Correct Answer: 1,2,3,4
Rationale: All of the products except for the furniture polish can cause burns since they are either alkalis or acids.
A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient?
1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
2. The wound is a partial-thickness burn, and could take up to two weeks to heal.
3. The wound is a superficial burn, and will take up to three weeks to heal.
4. The wound is a full-thickness burn and will take one to two weeks to heal.
5. Wound healing is individualized.
Correct Answer: 1
Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn.
In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess?
Select all that apply.
1. the depth of the burn
2. extent of burns on the body
3. the causative agent and the duration of exposure.
4. location of burns on the body
5. the time that the burn occurred
Correct Answer: 1,2,3,4
Rationale: Depth of the burn (the layers of underlying tissue affected) and extent of the burn (the percentage of body surface area involved) are used in determining the amount of tissue damage and classification of the burn.The causative agent is especially important with chemical burns such as from strong acids or alkaline agents. The location of the burns on the body is one of the important determinates of classification. For example, burns of the face and hands are always considered major burns. Time of occurrence of the burn is not necessary for classification.
A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following?
Select all that apply.
1. a superficial partial-thickness burn
2. a thermal burn
3. a superficial burn
4. a deep partial-thickness burn
5. a full-thickness burn
Correct Answer: 1,2
Rationale: Superficial partial-thickness burn if often bright red, has a moist, glistening appearance and blister formation. Thermal burns result from exposure to dry or moist heat. A superficial burn is reddened with possible slight edema over the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red with a dry, leathery, firm wound surface.
A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.
Correct Answer: 22.5
Rationale : The anterior trunk has superficial partial-thickness burns and is calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA.
A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following?
1. a moderate burn
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn
Correct Answer: 1
Rationale 1: A moderate burn is a partial-thickness injury that is between 15%-25% of total body surface area in adults.
A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury?
1. major
2. moderate
3. minor
4. superficial
5. intermediate
Correct Answer: 1
Rationale 1: Partial-thickness injuries of greater than 25% of total body surface area in adults and full-thickness injuries 10% or greater of TBSA are considered major burns.
A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn?
1. increasing fluid intake
2. applying mild lotions
3. taking mild analgesics
4. maintaining warmth
5. using sunscreen
Correct Answer: 1
Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure.
A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions?
(Select all that apply)
1. Report any fever to your healthcare provider.
2. Report development of purulent drainage to your healthcare provider.
3. Use only sterile dressings on the fingers.
4. Cleanse the areas every hour with alcohol to prevent infection.
5. Apply the topical antimicrobial agent as instructed.
Correct Answer: 1,2,3
Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare provider. Sterile dressings only should be used on the areas of the superficial partial-thickness burns where the skin is not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.
A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding?
1. inability of the damaged capillaries to maintain fluids in the cell walls
2. reduced vascular permeability at the site of the burned area
3. decreased osmotic pressure in the burned tissue
4. increased fluids in the extracellular compartment
5. the IV fluid being administered too quickly
Correct Answer: 1
Rationale: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments. Manifestations of fluid volume overload would be systemic, not localized to the burn areas.
A patient receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter. When evaluating the patient's intake and output, which of the following should be taken into consideration?
1. The amount of urine will be reduced in the first 24-48 hours, and will then increase.
2. The amount of urine output will be greatest in the first 24 hours after the burn injury.
3. The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins.
4. The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
5. The amount of urine is expected to be decreased for three to five days.
Correct Answer: 1
Rationale: The patient will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the patient will enter a period of diuresis. The diuresis begins between 24 and 36 hours after the burn injury.
The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would the nurse expect to see?
(Select all that apply)
1. glomerular filtration rate (GFR) reduced
2. specific gravity elevated
3. creatinine clearance reduced
4. BUN reduced
5. uric acid decreased
Correct Answer: 1,2
Rationale: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in reduction in GFR and an increase in specific gravity. During this period, BUN levels, creatinine, and uric acid are increased
When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated?
1. decreased hemoglobin and elevated hematocrit levels
2. elevated hemoglobin and elevated hematocrit levels
3. elevated hemoglobin and decreased hematocrit levels
4. decreased hemoglobin and decreased hematocrit levels
5. hemoglobin and hematocrit levels within normal ranges
Correct Answer: 1
Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration, and fluid shifts from the intravascular compartment.
When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings?
1. These values are normal for the patient's post-burn injury condition.
2. The patient is demonstrating manifestations consistent with the onset of an infection.
3. The patient is demonstrating manifestations consistent with an electrolyte imbalance.
4. The patient is demonstrating manifestations consistent with renal failure.
5. The patient is demonstrating manifestations of fluid volume overload.
Correct Answer: 1
Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response.
A patient has experienced a burn injury. Which of the following interventions by the nurse is of the highest priority at this time?
1. determination of the type of burn injury
2. determination of the types of home remedies attempted prior to the patient's coming to the hospital
3. assessment of past medical history
4. determination of body weight
5. determination of nutritional status
Correct Answer: 1
Rationale: Determination of the type of burn is the first step. The type of injury will dictate the interventions performed. Determining the use of home remedies, past medical history, body weight, and nutritional status must be completed, but are not of the highest priority.
A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements should the nurse include when instructing the patient prior to the procedure?
1. "You will begin to perform exercises to promote flexibility and reduce contractures after five days."
2. "You will need to report any itching, as it might signal infection."
3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure."
4. "The procedure will be performed in your room."
5. "You will need to be in protective isolation for several weeks after the graft is performed."
Correct Answer: 1
Rationale: The patient will begin to perform range-of-motion exercises after five days. Itching is not a symptom of infection but an anticipated occurrence that signals cellular growth. The ideal time to perform the procedure is early in the treatment of the burn injury. The procedure is performed in a surgical suite. Patients with skin grafts do not require protective isolation.
A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient?
1. morphine 4 mg IV every 5 minutes
2. morphine 10 mg IM ever 3-4 hours
3. meperidine 75 mg IM every 3-4 hours
4. meperidine 50 mg PO every 3-4 hours
5. fentanyl citrate (Duragesic) 75 mcg patch every 3 days
Correct Answer: 1
Rationale: Morphine is preferred over meperidine for the burn-injured patient. Typical dose of morphine is 3-5 mg every 5-10 minutes for an adult. The intravenous route is preferred over oral and intramuscular routes. A transdermal patch would not be used because of decreased absorption of the medication through the skin of the burn-injured patient.
A patient with a burn injury is prescribed silver nitrate. Which of the following nursing interventions should be included for the patient?
Standard Text: Select all that apply.
1. Monitor daily weight.
2. Monitor the serum sodium levels.
3. Prepare to change the dressings every two hours.
4. Report black skin discolorations.
5. Push fluid intake.
Correct Answer: 1,2
Rationale: Silver nitrate can cause hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by the determination of daily weights. Hyponatremia and hypochloremic alkalosis are common findings in patients treated with silver nitrate so serum sodium and chloride should be monitored. Changing the dressing every two hours is too frequent for the patient. Black discolorations of the skin are anticipated for patients using silver nitrate, and do not highlight a complication of therapy. Silver sulfadiazine, not silver nitrate, administration can result in the development of sulfa crystals in the urine so pushing fluid intake is not an appropriate action for this patient.
The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the following laboratory values is the best indicator of a need to adjust the nutritional program?
1. glycosuria
2. creatine phosphokinase (CPK)
3. BUN levels
4. hemoglobin
5. serum sodium levels
Correct Answer: 1
Rationale: Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient's nutritional plan. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury dependent upon the fluid status. Serum sodium levels are not indicative of nutritional status.
During the acute phase of burn treatment, important goals of patient care include which of the following?
Select all that apply.
1. providing for patient comfort
2. preventing infection
3. providing adequate nutrition for healing to occur
4. splinting, positioning, and exercising affected joints
5. assessing home maintenance management
Correct Answer: 1,2,3,4
Rationale: The goals of treatment for the acute period include wound cleansing and healing; pain relief; preventing infection; promoting nutrition; and splinting, positioning, and exercising affected joints. Assessment of home maintenance management is an important goal in the rehabilitative stage, not the acute stage.
A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially?
1. warmed lactated Ringer's solution
2. dextrose 5% with saline solution
3. dextrose 5% with water
4. normal saline solution
5. 0.45% saline solution
Correct Answer: 1
Rationale: Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia.
Using the modified Brooke formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg.
Correct Answer: 2080 mL
Rationale : The modified Brooke formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2 mL × 52 kg × 40 = 4160 mL. One-half is given over the first eight hours, or 2080 mL.
Place an "X" over the section of the diagram that represents the depth of a superficial partial-thickness burn. [insert Use figure 16-17 in LeMone 5E. Remove the caption and the labels on the right side (Clark's levels). Retain the left side labels (Skin layers). The Roman numeral labels in the drawing may remain if necessary.]
Rationale : A superficial partial-thickness burn damages the entire epidermis and through the papillary dermis.
The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the patient's leg. What is the most appropriate response by the nurse to this family?
1. "The scabs are really old burned tissue and need to be removed to promote healing."
2. "I'll ask the doctor to come and talk with you about the treatment plan."
3. "The patient asked for the scabs to be removed."
4. "The scabs are removed to check for blood flow to the burned area."
Correct Answer: 1
Rationale: The patient's family is describing eschar, which is the hard crust of burned necrotic tissue. Eschar needs to be removed to promote wound healing. Option 2 does not answer the family's question. Option 3 incorrectly restates the family's concern. Scabs are not removed to check for blood flow.
A patient with third-degree burns is prescribed gastrointestinal medication. The primary action of this drug is which of the following?
1. to prevent the onset of a Curling's ulcer
2. to treat a preexisting duodenal ulcer
3. to ensure adequate peristalsis
4. for the antiemetic properties
Correct Answer: 1
Rationale: Dysfunction of the gastrointestinal system is directly related to the size of the burn wound. This can lead to a cessation of intestinal motility, which causes gastric distention, nausea, vomiting, and hematemesis. Stress ulcers or Curling's ulcers are acute ulcerations of the stomach or duodenum that form following the burn injury. There is no evidence to support the presence of a preexisting duodenal ulcer. Although peristalsis is desired, it is not the primary area of gastrointestinal concern. There is no data presented to indicate the presence of nausea or vomiting.
A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should prepare which of the following solutions for intravenous infusion for this patient?
1. warmed lactated Ringer's
2. 5% dextrose in water
3. 5% dextrose in 0.45 normal saline
4. 5% dextrose in normal saline
Correct Answer: 1
Rationale: Warmed Ringer's lactate solution is the intravenous fluid most widely used during the first 24 hours after a burn injury because it most closely approximates the body's extracellular fluid composition.
The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum potassium level. The nurse realizes that this finding is consistent with which of the following?
1. the resolution of burn shock
2. the onset of burn shock
3. the onset of renal failure
4. the onset of liver failure
Correct Answer: 1
Rationale: Potassium levels are initially elevated during burn shock but will decrease after burn shock resolves as fluid shifts back to intracellular and intravascular compartments. Reduced potassium levels are not indicators of the onset of renal or liver failure.
A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. The nurse realizes that this patient most likely
1. is developing a hypersensitivity to the medication.
2. is reacting positively to the medication.
3. needs an increase in dosage of the medication.
4. is not responding to the medication.
Correct Answer: 1
Rationale: Approximately 3%-5% of patients develop a hypersensitivity to mafenide, which can manifest as facial edema. The manifestation of facial and neck edema is considered an adverse reaction. There is inadequate information presented to assess response to the medication.
Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes that this patient
1. will need to have the procedure repeated.
2. will no longer need this procedure.
3. will need to be premedicated prior to the next procedure.
4. should have an escharotomy instead.
Correct Answer: 1
Rationale: Surgical debridement is the process of excising the burn wound by removing thin slices of the wound to the level of viable tissue. If bleeding does not occur after the procedure, it will be repeated. It is an assumption that patients having debridement will all require premedication. An escharotomy involves removal of the hardened crust covering the burned area.
The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm. During wound care, the nurse applies Elase to the burned areas. Which of the following types ofwound debridement is this nurse using?
1. enzymatic
2. mechanical
3. surgical
4. topical
Correct Answer: 1
Rationale: Enzymatic debridement involves the use of a topical agent to dissolve and remove necrotic tissue. An enzyme such as Elase is applied in a thin layer directly to the wound and covered with one layer of fine mesh gauze. A topical antimicrobial agent is then applied and covered with a bulky wet dressing. Mechanical debridement may be performed by applying and removing gauze dressings, hydrotherapy, irrigation, or using scissors and tweezers. Surgical debridement is the process of excising the wound to the fascia or removing thin slices of the burn to the level of viable tissue. Topical treatments are key in the care of a burn but do not involve debridement.
A patient with third-degree burns is being treated with high-volume intravenous fluids and has a urine output of 40 cc per hour. The nurse realizes that this urine output
1. is normal for this patient.
2. provides evidence that the patient is dehydrated.
3. provides evidence that the patient is over-hydrated.
4. is indicative of pending renal failure.
Correct Answer: 1
Rationale: Intake and output measurements indicate the adequacy of fluid resuscitation, and should range from 30 to 50 mL per hour in an adult.
A patient with third-degree burns to his right arm is scheduled for passive range of motion to the extremity every two hours. Which of the following should the nurse do prior to this exercise session?
1. Medicate for pain.
2. Empty the patient's in-dwelling catheter collection bag.
3. Change the patient's bed linens.
4. Change the dressing on the burn.
Correct Answer: 1
Rationale: The nurse should anticipate this patient's needs for analgesia and administer pain medication to promote the patient's comfort during the exercise session. Arm exercise is not related to the amount of urine in the catheter bag. Linen changes do not impact range of motion activities. The burn's dressing is changed according to the physician's orders or as needed.
A patient with third-degree burns to her face just learned that she will have extensive scarring once the burn heals. Which of the following nursing diagnoses would be applicable to this patient at this time?
1. Powerlessness
2. Potential for Infection
3. Fluid Volume Deficit
4. Risk for Ineffective Airway Clearance
Correct Answer: 1
Rationale: This patient can begin to experience powerlessness in that she has no control over the outcome of healing on scar formation to her face. The nurse should allow the patient to express feelings in efforts to help the patient cope with the news of potential scarring. The patient with a third-degree burn is at risk for infection, however, this question is focused on the impact of her facial scarring. There is inadequate information to determine the patient's risk for fluid volume deficit or ineffective airway clearance. Further, this is not the focus of the question.
A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient most likely has experienced which of the following?
1. first-degree burn
2. superficial second-degree burn
3. deep second-degree burn
4. third-degree burn
Correct Answer: 2
Rationale: Partial-thickness, or second-degree, burns can either be superficial or deep. This patient's burn, which appears moist with blisters, is consistent with a superficial second-degree burn. A first-degree burn would involve only the surface layer of skin. Redness would be expected. Deep second-degree and third-degree burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue.
A female patient comes into the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. Which of the following should be the most important assessment for the nurse?
1. normal rest and sleep pattern
2. typical meal pattern
3. if the patient had to change time zones when traveling to the resort
4. if the patient has been sunburned
Correct Answer: 4
Rationale: Sunburns result from exposure to ultraviolet light. Because the skin remains intact, the manifestations in most cases are mild and are limited to pain, nausea, vomiting, skin redness, chills, and headache. The patient has not reported concerns which will support issues with sleep pattern, diet, and travel.
A patient comes into the physician's office after sustaining chemical burns to the left side of his face and right wrist. The nurse realizes that this patient needs to be treated
1. in the outpatient ambulatory clinic.
2. in the emergency department.
3. in a burn center.
4. in the doctor's office and then at home.
Correct Answer: 3
Rationale: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Patients having small or noninvasive burns may be managed at an outpatient clinic are mild in nature. The emergency department is a location for evaluation of a burn. The physician's office like the ambulatory clinic can manage mild burns.