NCLEX QUESTIONS AND BURN INJURY NURSING

Final (SET 5)BURN’S PEDIATRIC PRIMARY CARE

NCLEX QUESTIONS AND BURN INJURY NURSING

MANAGEMENT: SET 5 (20 Items) - Latest This

Summer

• Question

In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?• A. “Are you a smoker?” • B. “When was your last chest x-ray?” • C. “Have you ever had asthma or any other lung problem?” • D. “In what exact place or space were you when you were burned?” Incorrect

Correct Answer: D. “In what exact place or space were you when you were

burned?”

• Option D: The risk for inhalation injury is greatest when flame burns

occur indoors in small, poorly ventilated rooms.

• Option A: Although smoking increases the risk for some problems, it

does not predispose the client for an inhalation injury.

• Question

Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?• A. The client is able to talk.• B. The client is alert and oriented.• C. The client’s oxygen saturation is 97%.• D. The client’s chest movements are uninhibited.Incorrect

Correct Answer: C. The client’s oxygen saturation is 97%.

• Option C: Clients may have ineffective respiratory efforts and gas

exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

• Question

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection.Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?• A. Emergent Phase • B. Immediate Resuscitative Phase • C. Acute Phase • D. Rehabilitation Phase Incorrect

Correct Answer: C. Acute Phase

• Option C: The acute or intermediate phase of burn care follows the

emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care that includes wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting, pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.

• Option A & B: Priorities during the emergent or immediate

resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care.

• Option D: The priorities during the rehabilitation phase include

prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

• Question

The burned client’s family asks at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?• A. “When fluid remobilization has started.” • B. “When the burn wounds are closed.” • C. “When IV fluids are discontinued.” • D. “When body weight is normal.” Incorrect

Correct Answer: B. “When the burn wounds are closed.”

• Option B: Intact skin is a major barrier to infection and other

disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.