NCLEX Style Practice Questions Burns, Med Surg - Burns NCLEX Review Questions, Med Surg, Exams of Nursing

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NCLEX Style Practice Questions Burns, Med Surg - Burns

NCLEX Review Questions, Med Surg Exam 3 Burns

Questions, Med Surg: Chapter 25 Burns. Q & A 2024-

2025. Graded A

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?

1. a moderate burn
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn - ANSCorrect 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 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?
6. increasing fluid intake
7. applying mild lotions

3. taking mild analgesics
4. maintaining warmth
5. using sunscreen - ANSCorrect 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 female patient comes into the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. Which of the following should be the most important assessment for the nurse?
6. normal rest and sleep pattern
7. typical meal pattern
8. if the patient had to change time zones when traveling to the resort
9. if the patient has been sunburned - ANSCorrect Answer: 4 Rationale: Sunburns result from exposure to ultraviolet light. Because the skin remains intact, the manifestations in most cases are mild and are limited to pain, nausea, vomiting, skin redness, chills, and headache. The patient has not reported concerns which will support issues with sleep pattern, diet, and travel.

C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. - ANSB. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours. 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)

1. drain cleaners
2. household ammonia
3. oven cleaner
4. toiler bowl cleaner
5. lemon oil furniture polish - ANSCorrect Answer: 1,2,3,

Rationale: All of the products except for the furniture polish can cause burns since they are either alkalis or acids. 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?

1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the patient to prevent heat loss.
4. Move the patient indoors to a dry place.
5. Get the patient up off the ground. - ANSCorrect 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 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.
6. What type of current was involved?
7. How long was the patient in contact with the current?
8. How much voltage was involved?
9. Where was the patient when the burn occurred?

4. third-degree burn - ANSCorrect Answer: 2 Rationale: Partial-thickness, or second-degree, burns can either be superficial or deep. This patient's burn, which appears moist with blisters, is consistent with a superficial second-degree burn. A first-degree burn would involve only the surface layer of skin. Redness would be expected. Deep second-degree and third-degree burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. 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)
5. This is an alkali burn.
6. This type of burn tends to be deeper.
7. This is an acid burn.
8. This type of burn will be easier to neutralize.
9. This type of burn tends to be more superficial. - ANSCorrect Answer: 1, 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 comes into the physician's office after sustaining chemical burns to the left side of his face and right wrist. The nurse realizes that this patient needs to be treated

1. in the outpatient ambulatory clinic.
2. in the emergency department.
3. in a burn center.
4. in the doctor's office and then at home. - ANSCorrect Answer: 3 Rationale: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Patients having small or noninvasive burns may be managed at an outpatient clinic are mild in nature. The emergency department is a location for evaluation of a burn. The physician's office like the ambulatory clinic can manage mild burns. A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times a day. - ANSCorrect answer: b

2. determination of the types of home remedies attempted prior to the patient's coming to the hospital
3. assessment of past medical history
4. determination of body weight
5. determination of nutritional status - ANSCorrect 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. A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light - ANSANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution. - ANSANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients. 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?

1. major
2. moderate
3. minor

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds. - ANSANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially?

1. warmed lactated Ringer's solution
2. dextrose 5% with saline solution
3. dextrose 5% with water
4. normal saline solution

5. 0.45% saline solution - ANSCorrect Answer: 1 Rationale: Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia. A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? A. Singed nasal hair B. Generalized pallor C. Painful swallowing D. Burns on the upper extremities E. History of being involved in a large fire - ANSA, B, C, E. Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.

A. 18%

B. 22.5%

C. 27%

D. 36% - ANSB. 22.5%

Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. 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)

1. Report any fever to your healthcare provider.
2. Report development of purulent drainage to your healthcare provider.
3. Use only sterile dressings on the fingers.

4. Cleanse the areas every hour with alcohol to prevent infection.
5. Apply the topical antimicrobial agent as instructed. - ANSCorrect Answer: 1,2, 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?
6. inability of the damaged capillaries to maintain fluids in the cell walls
7. reduced vascular permeability at the site of the burned area
8. decreased osmotic pressure in the burned tissue
9. increased fluids in the extracellular compartment
10. the IV fluid being administered too quickly - ANSCorrect 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

A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to: a. arrange a return-to-clinic appointment and prescription for pain medications b. teach the patient and caregiver proper wound care to be performed at home c. review the patient's current health care status and readiness for discharge to home d. give the patient written discharge information and websites for additional information for burn survivors. - ANSCorrect answer: c Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.

A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements should the nurse include when instructing the patient prior to the procedure?

1. "You will begin to perform exercises to promote flexibility and reduce contractures after five days."
2. "You will need to report any itching, as it might signal infection."
3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure."
4. "The procedure will be performed in your room."
5. "You will need to be in protective isolation for several weeks after the graft is performed." - ANSCorrect Answer: 1 Rationale: The patient will begin to perform range-of-motion exercises after five days. Itching is not a symptom of infection but an anticipated occurrence that signals cellular growth. The ideal time to perform the procedure is early in the treatment of the burn injury. The procedure is performed in a surgical suite. Patients with skin grafts do not require protective isolation. 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?
6. The amount of urine will be reduced in the first 24-48 hours, and will then increase.