NCLEX Style Practice Questions Burns

NCLEX Style Practice Questions Burns Leave the first rating Students also studied Terms in this set (32) Science MedicineNursing Save

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15 terms ehender4Preview ATI Safety 20 terms Shelby_Nguyen7 Preview NCLEX Leadership 156 terms Kate383Preview Practic 124 term Lau 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. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn.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

Rationale: Depth of the burn (the layers of underlying tissue affected) and extent of the burn (the percentage of body surface area involved) are used in determining the amount of tissue damage and classification of the burn.The causative agent is especially important with chemical burns such as from strong acids or alkaline agents. The location of the burns on the body is one of the important determinates of classification. For example, burns of the face and hands are always considered major burns. Time of occurrence of the burn is not necessary for classification.

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. Thermal burns result from exposure to dry or moist heat. A superficial burn is reddened with possible slight edema over the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red with a dry, leathery, firm wound surface.A patient is brought to the emergency department with

the following burn injuries: a blistered and reddened

anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.

Correct Answer: 22.5

Rationale : The anterior trunk has superficial partial-thickness burns and is

calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA.A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following?

• a moderate burn
• a minor burn
• a major burn
• a severe burn
• an intermediate burn

Correct Answer: 1

Rationale 1: A moderate burn is a partial-thickness injury that is between 15%-25% of total body surface area in adults.A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury?

• major
• moderate
• minor
• superficial
• intermediate

Correct Answer: 1

Rationale 1: Partial-thickness injuries of greater than 25% of total body surface area in adults and full-thickness injuries 10% or greater of TBSA are considered major burns.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. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure.

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. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.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. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments. Manifestations of fluid volume overload would be systemic, not localized to the burn areas.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.A patient has experienced a burn injury. Which of the following interventions by the nurse is of the highest priority at this time?

• determination of the type of burn injury
• determination of the types of home remedies

attempted prior to the patient's coming to the hospital

• assessment of past medical history
• determination of body weight
• determination of nutritional status

Correct Answer: 1

Rationale: Determination of the type of burn is the first step. The type of injury will dictate the interventions performed. Determining the use of home remedies, past medical history, body weight, and nutritional status must be completed, but are not of the highest priority.