Burn (p. 484-506)

Question 1

An employee spilled industrial acids on the arms and legs at work. Before transporting the individual to the hospital, the occupational nurse at the facility should

a. cover the affected area with dry, sterile dressings.
b. flush the burned area with large amounts of tap water.
c. place cool compresses on the area of exposure.
d. apply an alkaline solution to the affected area.

Answer 1

Correct Answer: B
Rationale: With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

Cognitive Level: Application Text Reference: pp. 484, 489
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 2

A patient is admitted to the emergency department after suffering an electrical burn from exposure to a high-voltage current. In addition to the burn injuries, the most essential assessment is

a. blood urea nitrogen (BUN) and creatinine levels.
b. pupils’ reaction to light.
c. extremity movement.
d. peripheral pulses.

Answer 2

Correct Answer: C
Rationale: All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining cervical spine status.

Cognitive Level: Application Text Reference: pp. 486, 490
Nursing Process: Assessment NCLEX: Physiological Integrity

Question 3

When assessing an emergency department patient who spilled hot oil from a deep-fat fryer on the right leg and foot, the nurse notes that the leg and foot are red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as

a. full-thickness skin destruction.
b. deep partial-thickness skin destruction.
c. superficial partial-thickness skin destruction.
d. deep full-thickness skin destruction.

Answer 3

Correct Answer: B
Rationale: The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial thickness burns, the area is red, but no blisters are present.

Cognitive Level: Application Text Reference: p. 487
Nursing Process: Assessment NCLEX: Physiological Integrity

Question 4

Six hours after a thermal burn injury involving the anterior and posterior chest and both arms, the nurse obtains all of these data when assessing a patient. Which information is most important to communicate to the health care provider?

a. Blood pressure is 94/46 per arterial line.
b. Cardiac monitor shows a pulse rate of 104.
c. Urine output is 20 to 30 ml per hour.
d. Serous exudate is leaking from the burns.

Answer 4

Correct Answer: C
Rationale: The urine output should be at least 30 to 50 ml/hour during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

Cognitive Level: Analysis Text Reference: pp. 488, 492, 494, 496
Nursing Process: Assessment NCLEX: Physiological Integrity

Question 5

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 56%, Hb 17.2 mg/dl (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Based on these findings, the nurse should plan to

a. document the findings in the patient’s record.
b. continue to monitor the laboratory results.
c. increase the rate of the ordered IV solution.
d. type and crossmatch for a blood transfusion.

Answer 5

Correct Answer: C
Rationale: The patient’s lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate.

Cognitive Level: Application Text Reference: pp. 491-492
Nursing Process: Planning NCLEX: Physiological Integrity

Question 6

A patient is admitted to the burn unit with burns of the head, neck, chest, and back following a garage fire. Upon admission to the unit, the nurse auscultates wheezes in the patient’s lungs. One hour later, the wheezes cannot be heard, and lung sounds are decreased. The most appropriate action by the nurse is to

a. place the patient in high-Fowler’s position.
b. encourage the patient to cough and auscultate the lungs again.
c. document the results and continue to monitor the ventilation.
d. notify the health care provider about the breath sounds.

Answer 6

Correct Answer: D
Rationale: The patient with burns of the face and neck and with decreased breath sounds will require intubation and ventilatory assistance, and the health care provider should be notified so that this can be rapidly accomplished. 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.

Cognitive Level: Analysis Text Reference: pp. 492-493
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 7

During the early emergent phase of burns, the nurse will anticipate giving opioid analgesics by the IV route so that

a. the medications will be rapidly effective.
b. less frequent administration is needed.
c. larger doses of medications can be given.
d. respiratory depression can be easily treated.

Answer 7

Correct Answer: A
Rationale: Because medications administered by the oral or IM routes will not be rapidly effective, the nurse should administer medications IV. IV medications are rapidly metabolized, and frequent administration may be necessary. The dosage is not determined by the route, but by its effectiveness. The ease with which respiratory depression can be corrected is not a factor in choosing the route for medication administration in a burn patient.

Cognitive Level: Application Text Reference: p. 498
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 8

A patient with severe burns has fluid replacement ordered using the Parkland formula. The initial rate of administration is 1050 ml/hr. The nurse would expect that 18 hours after the burn occurred, the rate of the fluid administration should be _____ ml/hr.

a. 263
b. 350
c. 525
d. 1050

Answer 8

Correct Answer: C
Rationale: 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 525 ml/hr.

Cognitive Level: Application Text Reference: p. 497
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 9

The nurse determines that fluid replacement for a patient with major burns is adequate, based on the finding of

a. daily weight unchanged from admission.
b. BP of 90/58.
c. urinary output of 40 ml/hr.
d. total fluid intake equal to urinary output.

Answer 9

Correct Answer: C
Rationale: When fluid intake is adequate, the urine output will be at least 30 to 50 ml/hr. The patient’s weight and ratio of intake to output are not useful in this situation because of the effects of third spacing and evaporative fluid loss. A BP of 90/58 is an indication of hypovolemia in a patient who has had a major burn injury.

Cognitive Level: Application Text Reference: p. 496
Nursing Process: Evaluation NCLEX: Physiological Integrity

Question 10

The nurse admitting a patient with an extensive burn injury develops a nursing diagnosis of risk for imbalanced nutrition: less than body requirements related to high caloric needs. The initial action by the nurse should be to

a. encourage an oral intake of at least 5000 kcal per day.
b. administer multiple vitamins and minerals in the IV solution.
c. infuse total parenteral nutrition via a central catheter.
d. insert a feeding tube and give 20 ml/hr enteral feedings.

Answer 10

Correct Answer: D
Rationale: 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.

Cognitive Level: Application Text Reference: p. 499
Nursing Process: Planning NCLEX: Physiological Integrity

Question 11

A patient with deep partial-thickness and full-thickness burns of the face and chest has the wounds treated with the open method. The nurse identifies an expected patient outcome of absence of wound infections. An appropriate nursing action to help the patient meet the outcome is to

a. restrict all visitors prevent cross-contamination of wounds.
b. wear gowns, caps, masks, and gloves during all care of the patient.
c. use sterile water for cleansing and debridement in the hydrotherapy tank.
d. administer prophylactic antibiotics to prevent bacterial colonization of wounds.

Answer 11

Correct Answer: B
Rationale: 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. Restricting visitors is not necessary and will have adverse psychosocial consequences for the patient. Tap water is used during hydrotherapy, and hydrotherapy tanks are not usually used in burn care because of the risk of cross-contamination. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

Cognitive Level: Application Text Reference: p. 497
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

Question 12

When positioning a patient with burns of the head, neck, chest, and right arm and hand, the nurse places the patient

a. laterally with a small pillow under the head and the right arm and hand hyperextended.
b. supine with no pillow and the right arm and hand flexed in a position of comfort and elevated.
c. supine with a small pillow under the head and the right arm and hand elevated on a pillow.
d. in a Fowler’s position without a pillow with the right arm and hand extended and elevated on a pillow.

Answer 12

Correct Answer: D
Rationale: The patient should be placed in Fowler’s position to make ventilation easier. Pillows should not be used under the head of a patient with neck burns, and the arms and hands should be extended to avoid flexure contractures, even though this position will not be as comfortable for the patient.

Cognitive Level: Application Text Reference: p. 493
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 13

A patient with burns of the upper thorax and circumferential burns of both arms develops decreased radial pulses and loss of sensation in the fingers. The most appropriate action by the nurse is to

a. notify the health care provider.
b. increase the IV rate and re-evaluate (ROM) on the patient’s arms.
c. elevate the arms on pillows.

Answer 13

Correct Answer: A
Rationale: The decrease in pulses in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Increasing the IV rate may increase the blood flow to the arms slightly, but it will not address the cause of the decreased circulation. Passive ROM will not improve circulation to the arms. Elevating the arms on pillows will decrease circulation.

Cognitive Level: Application Text Reference: p. 491
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 14

Ranitidine (Zantac) is prescribed for a patient who had extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication?

a. Bowel sounds
b. Stool frequency
c. Stools for occult blood
d. Percent of meals eaten

Answer 14

Correct Answer: C
Rationale: H2-blockers are given to prevent Curling’s ulcer in the patient who has suffered burn injuries. H2-blockers do not impact on bowel sounds, stool frequency, or appetite.

Cognitive Level: Application Text Reference: pp. 499-500
Nursing Process: Evaluation NCLEX: Physiological Integrity

Question 15

Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit?

a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)
b. A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest
c. A 60-year-old patient who has twice-daily burn débridements and dressing changes to partial-thickness facial burns
d. A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

Answer 15

Correct Answer: A
Rationale: An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

Cognitive Level: Analysis Text Reference: pp. 492-506
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

Question 16

A patient with burns has the nursing diagnosis of pain related to lack of knowledge of pain-control methods. The most appropriate nursing action for this nursing diagnosis is to

a. request that the health care provider order a patient-controlled analgesia machine for the patient.
b. administer pain medications on a routine basis so that pain does not become out of control.
c. teach the patient how to use ordered analgesics with adjunctive methods such as guided imagery and relaxation.
d. use sedative or amnesic drugs in combination with opioids to reduce the perception of the pain experience.

Answer 16

Correct Answer: C
Rationale: Since the etiology of the pain is the patient’s lack of knowledge about pain control, teaching the patient about how to use adjunctive methods is an appropriate intervention. The other nursing actions may also be used to reduce pain but do not require any behavior change by the patient.

Cognitive Level: Application Text Reference: p. 503
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 17

A 21-year-old patient who has deep partial-thickness facial and neck burns has a nursing diagnosis of disturbed body image. The nurse evaluates that patient outcomes for this nursing diagnosis are met when the patient

a. starts to use make-up to cover up the scars.
b. expresses concern about the scar appearance.
c. realizes that scarring is temporary.
d. avoids using a pillow under the head.

Answer 17

Correct Answer: A
Rationale: The willingness to use strategies to enhance appearance is an indication that the problem has resolved. Expressing concern about the scars indicates a willingness to discuss the scars but does not indicate that the disturbed body image is resolved. Scarring from deep partial-thickness burns is permanent, although some improvement in scar appearance may occur. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

Cognitive Level: Application Text Reference: pp. 496, 504
Nursing Process: Evaluation NCLEX: Psychosocial Integrity

Question 18

A patient who was found unconscious in a burning bedroom and has burns to the lower legs is assessed by the nurse in the emergency department. The nurse notes that the patient’s face is bright red. Which of these actions should the nurse take first?

a. Elevate the legs on pillows.
b. Place the patient on 100% O2 using a non-breather mask.
c. Assess for singed nasal hair and dark oral mucous membranes.
d. Insert 2 large-bore IV lines.

Answer 18

Correct Answer: B
Rationale: The patient’s history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.

Cognitive Level: Application Text Reference: p. 484
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 19

The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when

a. the patient has been hospitalized for 48 hours.
b. blisters and edema have subsided.
c. white blood cell levels decrease.
d. the patient has large quantities of pale urine.

Answer 19

Correct Answer: D
Rationale: At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease based on the patient’s immune status and any infectious processes.

Cognitive Level: Application Text Reference: pp. 496, 499
Nursing Process: Comprehension NCLEX: Physiological Integrity

Question 20

Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?

a. Serum sodium, 146 mEq/L
b. BUN 36 mg/dl
c. Serum potassium 6.2 mEq/dl
d. Hct 52%

Answer 20

Correct Answer: C
Rationale: Hyperkalemia can lead to fatal bradycardias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life-threatening as the elevated potassium level.

Cognitive Level: Application Text Reference: p. 500
Nursing Process: Assessment NCLEX: Physiological Integrity

Question 21

The RN observes all of these actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?

a. The float nurse obtains burn cultures when the patient has a temperature of 95.2° F.
b. The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.
c. The float nurse administers as-needed fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.
d. The float nurse lowers room temperature to 76° F during the dressing change of a patient with large burns.

Answer 21

Correct Answer: D
Rationale: The patient with large burns requires a room temperature of 85° F degrees during dressing changes to avoid becoming hypothermic. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

Cognitive Level: Analysis Text Reference: p. 498
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

Question 22

. A patient in the acute phase of burn injury requires frequent hydrotherapy sessions for wound débridement. To evaluate for complications of hydrotherapy, the nurse will plan to closely monitor

a. serum sodium level.
b. lung sounds.
c. pulse quality.
d. daily urine output.

Answer 22

Correct Answer: A
Rationale: Hydrotherapy leads to loss of sodium from open burn areas into the bath water, which is hypotonic. Lung sounds, pulse quality, and urine output are not directly affected by hydrotherapy, although these assessments are also part of patient care.

Cognitive Level: Application Text Reference: p. 500
Nursing Process: Evaluation NCLEX: Physiological Integrity

Question 23

Two weeks after admission for major burns, a patient is continuing to lose weight despite a high-carbohydrate, high-protein diet. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements. In planning nursing interventions, the best between-meal snack for the patient would be

a. eggnog.
b. bagel.
c. nuts.
d. crackers and cheese.

Answer 23

Correct Answer: A
Rationale: Eggnog has the highest protein, calorie, and carbohydrates of the choices. Because the patient with a major burn is likely to be anorexic, it is important that the patient’s foods be nutrient dense.

Cognitive Level: Application Text Reference: p. 499
Nursing Process: Planning NCLEX: Physiological Integrity

Question 24

To provide wound care for the patient with deep partial-thickness and full-thickness burns, the nurse plans to

a. apply sterile wet-to-dry dressings to burned areas bid.
b. clean and scrub the wounds twice a week to remove eschar.
c. immerse the patient in a hydrotherapy tank for 30 minutes 4 times daily.
d. shower or bathe the patient daily to remove loose, necrotic skin.

Answer 24

Correct Answer: D
Rationale: Daily showers or baths are commonly used for wound debridement. Wet-to-dry dressings are not usually used because the dressings will pull away new dermis and epidermis. Although some dressings can remain in place for 3 days, the wounds are gently cleaned, not scrubbed. Hydrotherapy can lead to sodium loss and decreased body temperature and is not ordered 4 times daily.

Cognitive Level: Application Text Reference: pp. 496-497
Nursing Process: Planning NCLEX: Physiological Integrity

Question 25

Which of these nursing actions should be accomplished first for a patient who has suffered a burn injury while working on an electrical power line?

a. Obtain the patient’s vital signs.
b. Place a cervical collar on the patient.
c. Assess for the contact points.
d. Place on a cardiac monitor.

Answer 25

Correct Answer: B
Rationale: Cervical spine injuries are commonly associated with electrical burns; therefore, stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

Cognitive Level: Application Text Reference: pp. 486, 490
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 26

Which action should the nurse take first when caring for a patient who has just arrived in the emergency department with facial and chest burns caused by a house fire?

a. Ringer’s solution
b. Lung sounds
c. Size and depth
d. Ordered opioid

Answer 26

Correct Answer: B
Rationale: A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

Cognitive Level: Application Text Reference: p. 490
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 27

A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these health care provider orders should the nurse implement first?

a. Place on cardiac monitor.
b. Start 2 large bore IVs.
c. Assess for pain at contact points.
d. Apply dressings to burned areas.

Answer 27

Correct Answer: A
Rationale: After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start 2 IVs, assess for pain, and apply dressings.

Cognitive Level: Application Text Reference: pp. 486, 490
Nursing Process: Implementation NCLEX: Physiological Integrity

Question 28

A patient who has burns on the back and legs from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first?

a. Administer the ordered morphine sulfate IV.
b. Assess orientation and level of consciousness.
c. Use pulse oximetry to check the oxygen saturation.
d. Stay at the bedside and reassure the patient.

Answer 28

Correct Answer: C
Rationale: Agitation in a patient who may have suffered inhalation injury might indicate hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing loss of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

Cognitive Level: Application Text Reference: p. 492
Nursing Process: Implementation NCLEX: Physiological Integrity