NCLEX EXAM REVIEW SERIES Burn Injury Nursing Management (20 Questions)

NCLEX EXAM REVIEW SERIES Burn Injury Nursing Management (20 Questions). NCLEX EXAM REVIEW, Burns Review for Nursing Students

Introduction:

Questions about burn injury and it’s management often pop up in the NCLEX. Do not fear as these questions are relatively easy to answer as long as you know the basic concepts about burns. Challenge yourself to with this 20-item practice exam about burns.

Topics:
Burn Injury.
Nursing Management for Burn Injury.
Skin Grafting.
Contractures.

Question 1: A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge?
  
How to maintain home smoke detectors
Joining a community reintegration program    
Learning to perform dressing changes
Options available for scar removal

Question 1 Explanation:
Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All the other distractors are important in the rehabilitation stage. However, dressing changes have priority.

Question 2: A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first?

Begin intravenous fluids
Check the pulses with a Doppler device
Obtain a complete blood count (CBC)
Obtain an electrocardiogram (ECG)

Question 2 Explanation:
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action.

Question 3: A client who was burned has crackles and a respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first?
    
Administer digoxin
Perform chest physiotherapy
Monitor urine output
Place the client in an upright position

Question 3 Explanation:
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in the upright position can relieve the lung congestion immediately before other measures can be carried out. Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid. Monitoring urine output is important. However it is not an immediate intervention.

Question 4: How will the nurse position a client with a burn wound to the posterior neck to prevent contractures?
    
Have the client turn the head from side to side.
Keep the client in a supine position without the use of pillows.
Keep the client in a semi-Fowler’s position with her or his arms elevated.
Place a towel roll under the client’s neck or shoulder.

Question 4 Explanation:
The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion. The other distractors listed do not call for moving of the head from side to side. This movement is what would prevent contractures from occurring.

Question 5: On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action?
    
Documenting the findings
Loosening any dressings on the chest
Raising the head of the bed
Preparing for intubation

Question 5 Explanation:
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.

Question 6: Ten hours after the client with 50% burns is admitted, her blood glucose level is 140 mg/dL. What is the nurse’s best action?
    
Documents the finding
Obtains a family history for diabetes
Repeats the glucose measurement
Stops IV fluids containing dextrose

Question 6 Explanation:
Neural and hormonal compensation to the stress of the burn injury in the emergent phase increase liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this traumA. A family history of diabetes could make her more of a risk for the disease, but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The cause of her elevated blood glucose is not the IV fluid.

Question 7: The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury?
    
Full-thickness
Partial-thickness superficial
Partial-thickness deep
Superficial

Question 7 Explanation:
The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns are red to white in color.

Question 8: The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a “small amount of pain.” How will the nurse categorize this injury?

Full-thickness
Partial-thickness superficial
Partial-thickness deep
Superficial

Question 8 Explanation:
The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain.

Question 9: The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?
    
Current range of motion in all extremities
Heart rate and rhythm
Respiratory rate and pulse oximetry reading
Orientation to time, place, and person

Question 9 Explanation:
The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. Range of motion and neurologic assessments are important. However the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

Question 10: The client has severe burns around the right hip. Which position is most important to use to maintain maximum function of this joint?
    
Hip maintained in 30-degree flexion
Hip at zero flexion with leg flat
Knee flexed at 30-degree angle
Leg abducted with foam wedge

Question 10 Explanation:
Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.

Question 11: The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first?
    
Assesses level of consciousness and pupillary reactions
Ascertains the time food or liquid was last consumed
Auscultates breath sounds over the trachea and mainstem bronchi
Measures abdominal girth and auscultates bowel sounds

Question 11 Explanation:
Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important to assess oxygenation to the brain. Ascertaining time of last food intake is important in case intubation is necessary (the nurse would be more alert for the signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

Question 12: The client with a full-thickness burn is being discharged to home after a month in the hospital. His wounds are minimally opened and he will be receiving home care. Which nursing diagnosis has the highest priority?
    
Acute Pain
Deficient Diversional Activity
Impaired Adjustment
Imbalanced Nutrition: Less than Body Requirements

Question 12 Explanation:
Recovery from a burn injury requires a lot of work on the part of the client and significant others. The client is seldom restored to his or her preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.

Question 13: The client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse’s best response?
    
“Tagamet will stimulate intestinal movement.”
“Tagamet can help prevent hypovolemic shock.”
“This will help prevent stomach ulcers.”
“This drug will help prevent kidney damage.”

Question 13 Explanation:
Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement, prevent hypovolemic shock, or prevent kidney damage.

Question 14: The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?
    
“With reconstructive surgery, you can look the same.”
“We can remove the scars with the use of a pressure dressing.”
“You will not look exactly the same.”
“You shouldn’t start worrying about your appearance right now.”

Question 14 Explanation:
Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes.

Question 15: The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse’s best action?

Continuing to monitor the client
Increasing the temperature in the room
Increasing the rate of the intravenous fluids
Preparing to do a workup for sepsis

Question 15 Explanation:
These findings are associated with systemic gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out if the client has sepsis and treating it before it becomes a shock situation. Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action.

Question 16: The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse’s best response?
    
“As soon as he finishes his antibiotic prescription.”
“As soon as his albumin level returns to normal.”
“When fluid remobilization has started.”    
“When the burn wounds are closed.”

Question 16 Explanation:
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 high risk for infection as long as any area of skin is open.

Question 17: The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan?
    
Have chimneys swept every 2 years.
Keep a smoke detector in each bedroom.
Use space heaters instead of gas heaters.
Use carbon monoxide detectors only in the garage.

Question 17 Explanation:
Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom have a separate smoke detector. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby.

Question 18: The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?
 
Applies silver sulfadiazine (Silvadene) ointment
Covers the area with an elastic wrap
Places a synthetic dressing over the area
Removes loose nonviable tissue

Question 18 Explanation:
All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue.

Question 19: The nurse should teach the community that a minor burn injury could be caused by what common occurrence?
    
Chimney sweeping every year
Cooking with a microwave oven
Use of sunscreen agents
Use of space heaters

Question 19 Explanation:
Minor burns are common occurrences. The use of space heaters can cause a fire if clothing, bedding and other flammable objects are near them. Chimneys should be swept each year to prevent creosote build-up and resultant fire. Burn injuries do not commonly occur from microwave cooking, but rather when taking food from this oven. Lastly, sunscreen agents are recommended to prevent sunburn.

Question 20: The nurse uses topical gentamicin sulfate (Garamycin) on a client’s burn injury. Which laboratory value will the nurse monitor?
    
Creatinine
Red blood cells
Sodium
Magnesium level

Question 20 Explanation:
Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitoreD. Topical gentamicin will not affect the red blood cell count or sodium or magnesium level.

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