NCLEX Style Practice Questions Burns

NCLEX Style Practice Questions Burns patricia_harris50 Save Burns 30 terms jrmarquezPreview NCLEX Medications and other facts 707 terms DiaryofanNCLEXTa... Preview ms3 exam 1 79 terms awesomecamcas1897 Preview Chapte Teacher Em 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)

• This is an alkali burn.
• This type of burn tends to be deeper.
• This is an acid burn.
• This type of burn will be easier to neutralize.
• 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.

• What type of current was involved?
• How long was the patient in contact with the current?
• How much voltage was involved?
• Where was the patient when the burn occurred?
• 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?

• Check breathing and circulation.
• Look for entrance and exit wounds.
• Cover the patient to prevent heat loss.
• Move the patient indoors to a dry place.
• 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)

• drain cleaners
• household ammonia
• oven cleaner
• toiler bowl cleaner
• 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?

• The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
• The wound is a partial-thickness burn, and could take up to two weeks to heal.
• The wound is a superficial burn, and will take up to three weeks to heal.
• The wound is a full-thickness burn and will take one to two weeks to heal.
• 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.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.

• the depth of the burn
• extent of burns on the body
• the causative agent and the duration of exposure.
• location of burns on the body
• the time that the burn occurred

Correct Answer: 1,2,3,4

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.

• a superficial partial-thickness burn
• a thermal burn
• a superficial burn
• a deep partial-thickness burn
• 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.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?

• increasing fluid intake
• applying mild lotions
• taking mild analgesics
• maintaining warmth
• using sunscreen

Correct Answer: 1

Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important.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)

• Report any fever to your healthcare provider.
• Report development of purulent drainage to your healthcare provider.
• Use only sterile dressings on the fingers.
• Cleanse the areas every hour with alcohol to prevent infection.
• 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.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?

• inability of the damaged capillaries to maintain fluids in the cell walls
• reduced vascular permeability at the site of the burned area
• decreased osmotic pressure in the burned tissue
• increased fluids in the extracellular compartment
• 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.

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?

• The amount of urine will be reduced in the first 24-48 hours, and will then increase.
• The amount of urine output will be greatest in the first 24 hours after the burn injury.
• The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins.
• The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
• 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)

• glomerular filtration rate (GFR) reduced
• specific gravity elevated
• creatinine clearance reduced
• BUN reduced
• 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?

• decreased hemoglobin and elevated hematocrit levels
• elevated hemoglobin and elevated hematocrit levels
• elevated hemoglobin and decreased hematocrit levels
• decreased hemoglobin and decreased hematocrit levels
• 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?

• These values are normal for the patient's post-burn injury condition.
• The patient is demonstrating manifestations consistent with the onset of an infection.
• The patient is demonstrating manifestations consistent with an electrolyte imbalance.
• The patient is demonstrating manifestations consistent with renal failure.
• 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.