BURN NCLEX EXAM QUESTION WITH CORRECT

BURN NCLEX EXAM QUESTION WITH CORRECT

ANSWERS AND RATIONALES 2023-2024 1 / 4

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?Monitor intake and output Administer antibiotics Monitor respiratory status 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 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.Infection is serious health risk for clients who sustained major burns, and antibiotic therapy is probable; however, another action is the priority.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 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. 2 / 4

Which of the following interventions should the nurse include in the plan?Initiate range of motion exercises Use clean technique to provide wound care Place the client on low protein diet 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:

The nurse should use sterile technique to provide wound care for this client to reduce the risk of infection.The nurse should place the client on a high-protein, high-calorie diet to promote wound healing.The nurse should encourage the client to ambulate frequently to promote mobility and improve ventilation.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?“May I go with my family to visitor’s lounge?” “I’ll see my friends when I get home” “My dad is coming to visit me. Can you fix my hair for me?” 3 / 4

“I told my cousins I’m in protective custody.”

Correct Answer: A. “May I go with my family to the lounge?” Incorrect

Answers:

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.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.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. A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client’s voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema Bacterial pneumonia Inhalation injury Carbon monoxide poisoning Answer C. Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider.

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