BURNS: NCLEX Questions REVEW

Question 1

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

1. Equation to calculate acceptable urine output for this client?
2. What is the goal of fluid resuscitation?

Answer 1

A urine output consistently above 40 ml/hour

In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn’t a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.

Question 2

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Hint: Smelly and cloth that instantly lights on fire

Answer 2

You selected: Mafenide (Sulfamylon)

Ma/fe/nide (Sulfa/mylon)

Question 3

Purposes of a skin graft include the (4)

Answer 3

Purposes of a skin graft include the

reduction of scarring and contractures,

to decrease evaporative fluid loss,

decrease the potential for infection, and

speed recovery

Question 4

What type of burns will require a skin graft?

Answer 4

1. Full Thickness (maybe)
2. Deep Full Thickness

Very small third-degree burns may heal on their own, but this process takes a very long time. Any third-degree burn larger than a fifty-cent piece must be grafted or it will not heal.

Question 5

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
You selected: Normal saline solution with 20 mEq of potassium per 1,000 ml
Incorrect
Correct response: Lactated Ringer’s solution but maybe NS without potassium

Two reasons to use Lactated Ringer’s
Explanation:
Lactated Ringer’s solution

1. replaces lost sodium and
2. corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn’t given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental

Answer 5

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
You selected: Normal saline solution with 20 mEq of potassium per 1,000 ml
Incorrect
Correct response: Lactated Ringer’s solution
Explanation:
Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn’t given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental

Question 6

1. A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
2. When do fat emboli generally occur?

Answer 6

Related to circumferential eschar

As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility.

This client isn’t likely to develop fat emboli unless long bone or pelvic fractures are present

. Infection doesn’t alter physical mobility. A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion.

Question 7

A client presents with blistering wounds caused by an unknown chemical agent.

How should the nurse intervene?

Answer 7

You selected: Irrigate the wounds with water FIRST!

Question 8

Which zone consists of the area where the injury is most severe and deepest?

a) Stasis
b) Coagulation
c) Hyperemia
d) Necrosis

Answer 8

Coagulation
Explanation:

1. The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest.
2. The zone of stasis is the area of intermediate burn injury.
3. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged.
4. There is no zone of necrosis.

Question 9

Which of the following interventions help minimize risk of further injury to an affected person at a scene of a fire? Choose all correct options.

a) Avoid immediate IV fluid therapy
b) Place the client in a horizontal position
c) Roll the client in a blanket
d) Place the client with the head positioned slightly below the rest of the body

Answer 9

b) Place the client in a horizontal position
c) Roll the client in a blanket

The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage.

Question 10

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:

a) apply maximum bandages to allow for absorption of drainage.
b) wrap elastic bandages distally to proximally on dependent areas.
c) wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return.
d) remove bandages with clean gloves.

Answer 10

b) wrap elastic bandages distally to proximally on dependent areas.

Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client’s arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn’t use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.

Question 11

A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

a) The client exhibits metabolic alkalosis.
b) The client’s urinary output has fallen below 30 ml/hour.
c) The client’s serum sodium levels are elevated.
d) The client’s complete blood count readings reflect a reduced hematocrit.

Answer 11

d) The client’s complete blood count readings reflect a reduced hematocrit.

During the intermediate phase of burn care, the client’s hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases.

Question 12

** Loss of serum sodium** leads to

metabolic acidosis or metabolic alkalosis?

During ACUTE/INTERMEDIATE Phase

Answer 12

Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis

Question 13

Which of the following topical burn preparations act as wick for sodium and potassium?

a) Mafenide acetate (Sulfamylon)
b) Acticoat
c) Silver sulfadiazine (Silvadene)
d) Silver nitrate solution

Answer 13

Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.

Question 14

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:

a) body image.
b) fluid resuscitation.
c) infection.
d) pain management.

Answer 14

d) pain management.

With a superficial partial-thickness burn such as a solar burn, the nurse’s main concern is **pain management **Body image disturbance is a concern that has lower priority than pain management.

Question 15

Fluid resuscitation and infection become concerns if the burn extends to the ? and ? skin layers.

Answer 15

Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers like “Full Thickness Burns”

Question 16

Choice Multiple question – Select all answer choices that apply.
Which of the following is to be expected soon after a major burn? Select all that apply.

a) Hypertension
b) Tachycardia
c) Hypotension
d) Bradycardia
e) Anxiety

Answer 16

b) Tachycardia
c) Hypotension

e) Anxiety

Question 17

Which of the following is the preferred IV fluid for burn resuscitation?

a) Total parenteral nutrition (TPN)
b) D5W
c) Lactated Ringer’s (LR)
d) Normal saline (NS)

CHECK THIS QUESTION WITH AUTH PPT

Answer 17

LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation. (

Question 18

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?

a) 7 to 10 days
b) 2 days
c) 3 days
d) 5 days

Answer 18

5 days
Explanation:
Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.