Burns NCLEX questions
The nurse is teaching first aid measures to a group of adolescents about appropriate treatment for burns. The nurse should anticipate the need for further teaching when one of the adolescents makes which statement?
"It is appropriate to place butter on the burn."
A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?
100% humidified oxygen by face mask
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client?
100% oxygen via a tight-fitting non-rebreather face mask
A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?
19%
An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?***
22.5%
An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury? Refer to the figure.<
31.5%
The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury should be which percentage?
36%
Several clients arrive simultaneously at the emergency department after sustaining burn injuries in a house fire. Which client will require the closest observation for signs of respiratory distress?
A client who has singed nasal hairs and worsening hoarseness
The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.
A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.
A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?
Appearance
A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions should the nurse take before transferring the client to the burn center? Select all that apply.
Apply cool water to the area. Wrap burned fingers separately to prevent sticking together. Cover the burns with a clean dry cloth as directed by a burn center.
The nurse is caring for a client with a burn injury to the lower legs. Silver sulfadiazine is prescribed to be applied to the sites of injury. Which indicates the appropriate method to apply this medication?
Apply to cleansed, debrided wounds as prescribed.
The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which?*****
Autograft
The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?
Carry the client to fresh air.
A client with a burn injury is applying mafenide acetate to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. Which instructions should the nurse reinforce to the client?
Continue with the treatment because this is expected.
A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury?***
Elevated hematocrit levels
A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect?
Hyperventilation
A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem?
Hypoxia
The nurse is reinforcing sun exposure precautions to a group of older clients. Which should the nurse include in the instructions? Select all that apply.
It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm. Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. Apply sunscreen liberally 15 to 30 minutes before sun exposure.
The client is receiving a full-thickness graft to a burn on the hand. The nurse understands that a full-thickness graft is being applied instead of a split-thickness graft because of which reason?
It provides better cosmetic results.
The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation?
Level of consciousness
The primary health care provider has prescribed a bacteriostatic agent effective against both gram-positive and gram-negative organisms for application to a burn wound. The nurse determines that which medication has been prescribed
Mafenide acetate
A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform?
Place the child's hand under cool running water
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?
The return of distal pulses
An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?
Use of accessory muscles for breathing
Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse?
White blood cell count of 3000 mm3 (3.0 × 109/L) - leukopenia
A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.
Hoarse voice Guttural respiratory sounds
The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client?
Tachycardia
A client presents to the urgent care center with a chemical burn of the right eye. The priority for the nurse is to prepare the client for which nursing intervention?
Flushing the right eye with copious amounts of sterile solution
The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?
Notify the registered nurse.
During the emergent phase of a client with severe burns the nurse expects to perform which action?
Insert a Foley catheter.
The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply.
Acute, Resuscitative, Rehabilitative
A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which will be prescribed initially?
Insertion of a nasogastric tube
The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?
"I need to avoid sun exposure before 10:00 am and after 4:00 pm."
Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?
"I will apply the ointment once a day and cover it with a sterile dressing."
Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
"The medication is likely to cause stinging initially."
The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?
I should never wear warm clothing over the newly healed skin area.
A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?
Chicken breast, broccoli, strawberries, and milk3
The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first?
Peripheral pulses
A client has sustained full-thickness circumferential burns of the trunk. Which should be the priority concern of the nurse?
Client's ability to adequately ventilate
During the emergent phase after a major burn injury, which abnormalities should the nurse expect to note?
Increased hematocrit and increased potassium
A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?
Inserting a Foley catheter
The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?***
Monitor the client for signs of infection.
A client with a major burn is admitted to the emergency department. In priority order, which actions should the nurse take?
1 Establish airway. Initiate fluid therapy. 2 Initiate fluid therapy. Insert Foley catheter. 3 Insert Foley catheter. Insert a nasogastric tube. 4 Insert a nasogastric tube.
The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client?
Elevating and immobilizing the affected leg
An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.
36%
The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?
Elevation above the level of the heart
The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?
Tachycardia, cold skin, and hypotension
A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which should the nurse include in the plan of care? Select all that apply.
Monitoring the donor site and the graft site for signs of infection. Administering pain medications as prescribed
