Exam 3: Burns NCLEX Questions

c

The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patients orientation. c. Place the patient on 100% oxygen using a non-rebreather mask. d. Assess for singed nasal hair and dark oral mucous membranes.

d

Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago? a. Hct 52% b. BUN 36 mg/dL c. Serum sodium 146 mEq/L d. Serum potassium 6.2 mEq/L

c

What is the priority nursing assessment when caring for a patient who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

d

Which of these snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment? a. Strawberry gelatin b. Whole wheat bagel c. Chunky applesauce d. Chocolate milkshake

c

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? a. pulmonary edema b. bacterial pneumonia c. inhalation injury d. carbon monoxide poisoning

a

During the rehabilitation phase of a burn injury, what can control the contour of the scarring? a. pressure garments b. avoidance of sunlight c. splinting the joints in extension d. application of emollient lotions

d

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? a. Serum sodium and potassium increase. b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.

a c d

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hours ago. Which of the following are findings common during this phase? Select all that apply a. temperature of 97°F (36.1°C) b. bradycardia c. hyperkalemia d. hyponatremia e. decreased hematocrit

c

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls b. movement of potassium into the vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of RBC from large volumes of rapidly administered fluid

a

The nurse initially suspects the possibility of sepsis in the burn patient based on which change? a. vital signs b. urinary output c. GI function d. burn wound appearance

b

A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will be included in the plan of care? a. Restrict all visitors to prevent cross-contamination of wounds. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Turn the room temperature up to at least 68 F (20 C) during dressing changes. d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

b

A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these prescribed interventions should the nurse implement first? a. Start two large bore IVs. b. Place on cardiac monitor. c. Apply dressings to burned areas. d. Assess for pain at contact points

d e

Which characteristics accurately describe chemical burns? Select all that apply a. metabolic asphyxiation may occur b. metabolic acidosis occurs immediately following the burn c. the visible skin injury often does not represent the full extent of tissue damage d. lavaging with large amounts of water is important to stop the burning process with these injuries e. alkaline substances that cause these burns continue to cause tissue damage even after being neutralized

b

Which client with burns will most likely require an ET or tracheostomy tube? A client who has a. electrical burns of the hands and arms causing arrhythmias b. thermal burns to the head, face, and airway resulting in hypoxia c. chemical burns on the chest and abdomen d. secondhand smoke inhalation

b

A burn patient has a nursing diagnosis of impaired physical mobility related to a limited ROM resulting from pain. What is the best nursing intervention for this patient? a. have the patient perform ROM exercises when pain is not present b. provide analgesic medication before physical activity and exercise c. teach the patient the importance of exercise to prevent contractures d. arrange for the physical therapist to encourage exercise during hydrotherapy

d

A client arrives at the ED following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? a. 100% oxygen via an aerosol mask b. oxygen via nasal cannula at 6 LPM c. oxygen via nasal cannula at 15 LPM d. 100% oxygen via a tight-fitting, nonrebreather face mask

b c e

A client is brought to the ED with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply a. restrict fluids b. assess for airway patency c. administer oxygen as prescribed d. place a cooling blanket on the client e. elevate extremities if no fractures are present

c

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a BP of 90/50, pulse of 110, and urine output of 20 ml/hr. The nurse reports the findings to the HCP and anticipates which prescription? a. transfusing 1 unit of packed RBCs b. administering a diuretic to increase urine output c. increasing the amount of IV LR solution administered per hour d. changing the IV LR solution to one that contains 5% dextrose in water

a c e

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? Select all that apply a. limit visitors in the client's room b. encourage fresh vegetables in the diet c. increase protein intake d. instruct the client to consume 2,000 calories/day e. restrict fresh flowers in the room

c

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? a. subcutaneous b. oral c. intravenous d. transdermal

d

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? a. Severe pain, blisters, and blanching with pressure b. Pain, minimal edema, and blanching with pressure c. Redness, evidence of inhalation injury, and charred skin d. No pain, waxy white skin, and no blanching with pressure

d

A patient has 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. What is most important for a nurse to assess in this patient? a. presence of pain b. swelling of the arm c. formation of eschar d. presence of pulses in the arms

b

A patient has 25% TBSA burn 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 between dressing changes d. wash the wound aggressively with soap and water 3 times a day

d

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultated wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. encourage the patient to cough and auscultate the lungs again b. obtain vital signs, oxygen saturation, and a STAT ABG c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician

b

A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. 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 patients respiratory rate. d. Reposition the patient in high-Fowlers position and reassess breath sounds.

d

The client with a major burn injury receives total parenteral nutrition. The expected outcome is to a. correct water and electrolyte imbalances b. allow the GI tract to rest c. provide supplemental vitamins and minerals d. ensure adequate caloric and protein intake

a

The injury that is least likely to result in a full-thickness burn is a. sunburn b. scald injury c. chemical burn d. electrical injury

b

The nurse assesses that bowel sounds are absent and abdominal distention is present in a patient 12 hours post-burn. The nurse notifies the HCP and anticipates doing what action next? a. withhold all oral intake except water b. insert a NG tube for decompression c. administer a H2 histamine blocker such as rantidine d. administer nutritional supplements through a feeding tube placed in the duodenum

c

The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when a. white blood cell levels decrease. b. blisters and edema have subsided. c. the patient has large quantities of pale urine. d. the patient has been hospitalized for 48 hours.

a

To maintain a positive nitrogen balance in a major burn area, the patient must a. eat a high-protein, high-carbohydrate diet b. increase normal caloric intake by about three times c. eat at least 1500 calories/day in small, frequent meals d. eat a gluten-free diet for the chemical effect on nitrogen balance

a

To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to 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.

b

What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? a. fever b. shivering c. severe pain d. unconsciousness

c

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as a. full-thickness skin destruction. b. deep full-thickness skin destruction. c. deep partial-thickness skin destruction. d. superficial partial-thickness skin destruction.

a d e

When assessing a patient with a partial-thickness burn, the nurse would expect to find Select all that apply a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

a

When assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? a. leathery, dry, hard skin b. red, fluid-filled vesicles c. massive edema at the injury site d. serous exudate on a shiny, dark brown wound

c

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. Mannitol 75 g IV b. Urine for myoglobulin c. Lactated Ringer's solution at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours

c

A 24 year old female patient does not want the wound cleansing and dressing change to take place. She asks, "what difference will it make anyway?" What will the nurse encourage the patient to do? a. have the wound cleaned and the dressing changed b. have a snack before having the treatments completed c. talk about what is troubling her with the nurse or family d. call the chaplain to come and talk to her and convince her to have the care

c

After the initial phase of the burn injury, the client's plan of care will focus primarily on a. helping the client maintain a positive self-concept b. promoting hygiene c. preventing infection d. educating the client regarding care of the skin grafts

c

An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? a. Cook for her. b. Stop her from smoking. c. Install tap water anti-scald devices. d. Be sure she uses an open space heater.

c

At about a half hour before the daily whirlpool bath and dressing change, the nurse should a. soak the dressing b. remove the dressing c. administer an analgesic d. slit the dressing with blunt scissors

a b c e

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 the nurse 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

d

A patient who has burns on the back and chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

a

A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? a. Tachycardia b. Restlessness c. Hypokalemia d. Gastrointestinal (GI) distress

a

A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both arms above heart level with pillows. d. Encourage the patient to flex and extend the fingers.

c

A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? a. Replace the blood lost. b. Maintain a neutral pH. c. Maintain fluid balance. d. Replace serum potassium.

a

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments b. repositioning the patient every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water-based moisturizers

d

After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take? a. Apply an alkaline solution to the affected area. b. Place cool compresses on the area of exposure. c. Cover the affected area with dry, sterile dressings. d. Flush the burned area with large amounts of water.

b

After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who has a dressing change scheduled d. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

d

During the early phase of burn care, the nurse should assess the client for a. hypernatremia b. hyponatremia c. metabolic alkalosis d. hyperkalemia

d

During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

c

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? a. Sit or lie in the position of comfort. b. Wear a pressure garment for 8 hours each day. c. Refer the patient to a counselor for psychosocial support. d. Use the sun to increase the skin color on the healed areas.

c

How is the immune system altered in a burn injury? a. bone marrow stimulation b. increase in immunoglobulin levels c. impaired function of WBC d. overwhelmed by microorganisms entering denuded tissues

c

How should the nurse position the patient with ear, face, and neck burns? a. prone b. on the side c. without pillows d. with extra padding around the head

a c d

Pain management for the burn patient is most effective when Select all that apply a. a pain rating tool is used to monitor the patient's level of pain b. painful dressing changes are delayed until the patient's pain is completely relieved c. the patient is informed about and has some control over the management of the pain d. a multimodal approach is used (short-acting opioids, NSAIDs, adjuvant analgesics) e. nonpharmacologic therapies replace opioids in the rehabilitation phase of a burn injury

d

Six hours after a thermal burn covering 50% of a patients total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider? a. Blood pressure is 94/46 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 104. d. Urine output is 20 mL per hour for the past 2 hours.

a b

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation? Select all that apply a. Urine output is 46 mL/hr. b. Heart rate is 94 beats/min. c. Urine specific gravity is 1.040. d. Mean arterial pressure is 54 mm Hg. e. Systolic blood pressure is 88 mm Hg.

c

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? a. out of bed activities b. bathroom privileges c. immobilization of the affected leg d. placing the affected leg in the dependent position

b

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noticing which sign in the client? a. coma b. flushing c. dizziness d. tachycardia

d

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the emergent phase of the burn injury? a. decreased HR b. increased urinary output c. increased BP d. elevated hematocrit levels

c

The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? a. pulse rate of 112 bpm b. BP of 94/64 c. urine output of 30 ml/hr d. serum sodium level of 136

b

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? a. Skin is hard with a dry, waxy white appearance. b. Skin is shiny and red with clear, fluid-filled blisters. c. Skin is red and blanches when slight pressure is applied. d. Skin is leathery with visible muscles, tendons, and bones.

d

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods

b

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? a. Blisters b. Reddening of the skin c. Destruction of all skin layers d. Damage to sebaceous glands

d

The nurse is conducting a focused assessment of the GI system of a client with a burn injury. The nurse should assess the client for a. paralytic ileus b. gastric distention c. hiatal hernia d. Curling's ulcer

a c d e

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care? Select all that apply a. Escharotomy b. Administration of diuretics c. IV and oral pain medications d. Daily cleansing and debridement e. Application of topical antimicrobial agent

b

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? a. Begin IV fluid replacement. b. Monitor for signs of complications. c. Assess and manage pain and anxiety. d. Discuss possible reconstructive surgery.

a

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? a. Morphine b. Sertraline c. Zolpidem d. Enoxaparin

a

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? a. Administer 100% humidified oxygen. b. Teach the patient deep breathing exercises. c. Encourage the patient to express his feelings. d. Assist the patient to a high Fowler's position.

d

The nurse should plan to begin rehabilitation efforts for the burn client a. immediately after the burn has occurred b. after the client's circulatory status has been stabilized c. after grafting of the burn has occurred d. after the client's pain has been eliminated

b

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? a. Subcutaneous (SQ) tetanus toxoid b. Intravenous (IV) morphine sulfate c. Intramuscular (IM) hydromorphone d. Oral oxycodone and acetaminophen

b c

When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply a. The exercises are the only way to prevent contractures. b. Active and passive ROM maintain function of body parts. c. ROM will show the patient that movement is still possible d. Movement facilitates mobilization of leaked exudates back into the vascular bed. e. Active and passive ROM can only be done while the dressings are being changed.

b

Which action will be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

c

Which burn patient should have orotracheal or endotracheal intubation? a. carbon monoxide poisoning b. electrical burns causing cardiac dysrhythmias c. thermal burn injuries to the face, neck, or airway d. respiratory distress from eschar formation around the chest

b

Which of these actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire? a. Infuse the ordered IV solution. b. Auscultate the patients lung sounds. c. Determine the extent and depth of the burns. d. Administer the ordered opioid pain medications.

d

Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement? a. ketorolac (Toradol) b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

b

Which of these nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.