TIP: One useful tip in answering NCLEX questions is prioritizing based on patient’s needs e.g., using Maslow’s Hierarchy of needs.
“Success means doing the best we can with what we have. Success is the doing, not the getting; in the trying, not the triumph. Success is a personal standard, reaching for the highest that is in us, becoming all that we can be.”
– Zig Ziglar
Topics or concepts included in this exam are:
- Carbon Monoxide Poisoning.
- Phases of Management of the Burn Injury.
- Rule of Nines.
To make the most out of this quiz, follow the guidelines below:
- Read each question carefully and choose the best answer.
- You are given one minute per question. Spend your time wisely!
- Answers and rationales (if any) are given below. Be sure to read them.
- If you need more clarifications, please direct them to the comments section.
In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be given after you’ve finished the quiz.
NCLEX Exam: Burn Injury Nursing Management 3 (20 Items)
Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.
NCLEX Exam: Burn Injury Nursing Management 3 (20 Items)
Text Mode: All questions and answers are given on a single page for reading and answering at your own pace. Be sure to grab a pen and paper to write down your answers.
1. Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed?
1. Cover the wound using a sterile gauze dressing.
2. Administer Tramadol (Tramal) 50 mg IV.
3. Debride the wound of eschar using gauze sponges.
4. Apply silver nitrate ointment.
5. Obtain sample for wound culture.
2. Which of the following medications given to a 12-year-old client for the treatment of deep partial thickness burn is the most important to double check with another licensed nurse before administering it?
3. The nurse is administering fluids intravenously as ordered to a client who acquired full-thickness burn injury on the abdomen. To determine the sufficiency of fluid resuscitation, the nurse would monitor which of the following that would provide the most reliable parameter for determining the adequacy?
A. Level of consciousness.
B. Peripheral pulses.
C. Urine output.
D. Vital signs.
4. Nurse Rodrigo is receiving an endorsement from the burn unit. Which of the following clients should he assess first?
A. A client who has just been transferred from the PACU after having allograft.
B. A client admitted 1 week ago with a superficial-thickness burn on the buttocks which has been waiting for 2 hours to receive discharge instructions.
C. A client who has just arrived from the emergency department with burns on the neck and chest.
D. A client with deep partial-thickness burns on both thighs who is complaining of severe and continuous pain.
6. Nurse Cirie is caring for a client who suffered a smoke inhalation injury. The carbon monoxide report reveals a level of 35%. Based on the level, which of the following signs should the nurse expect in the client?
7. A client is brought to the emergency unit with third-degree burns on the posterior trunk, right arm, and left posterior leg. Using the Rule of Nines, what is the total body surface area that has been burned?
8. A medicine student arrives at the emergency unit due to a burn injury that occurred inside the laboratory and an inhalation injury is suspected. Which of the following is the appropriate oxygen therapy for the client?
A. Oxygen via nasal cannula at 5 L/min.
B. Oxygen via a tight fitting, non-rebreather face mask at 100% concentration.
C. Oxygen via nasal cannula at 10 L/min.
D. Oxygen via Venturi mask at 30% Fi02.
9. The nurse is handling a client who sustained electrical burn on the arm and wrist and is scheduled for a fasciotomy. After the procedure, the nurse should assess the affected extremity in which of the following EXCEPT?
C. Distal circulation.
D. All of the above.
10. The nurse is caring for a client with a burn wound on the left knee and an autograft and skin grafting was performed. Which of the following activity will be prescribed for the client post op?
A. Elevation and immobilization of the affected leg.
B. Placing the affected leg in a dependent position.
C. Dangling of legs.
D. Bathroom privileges.>
11. Nurse Troyzan has just received the change-of-shift report in the burn unit. Which of the following client requires the most immediate care?
A. A 50-year-old who was admitted with electrical burns 24 hours ago and has a serum potassium level of 5 mEq/L.
B. A 40-year-old with partial thickness leg burns which has a temperature of 101.9°F and a blood pressure of 89/42 mm Hg.
C. A 30-year-old who returned from debridement surgery 3 hours ago and is complaining of pain (Pain scale of 7/10).
D. A 25-year-old admitted 4 days previously with facial burns due to a house fire which has been crying since recent visitors left.
12. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
A. Increased blood pressure.
B. Increased hematocrit levels.
C. Decreased heart rate.
D. Increased urine output.
13. The nurse manager is observing a new nursing graduate caring for a burned client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?
A. Performing strict handwashing techniques.
B. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and a plastic apron.
C. Using sterile bed sheets and linens.
D. Wearing gloves and a gown only when giving direct care to the client.
14. A client is undergoing fluid replacement after being burned 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of 25 ml over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders?
A. Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour.
B. Transfusing 1 unit of packed red blood cells.
C. Administering diuretic to increase urine output.
D. Changing the IV lactated Ringer’s solution into dextrose in water.
15. Nurse Kelsey is a nurse manager assigned in the burn unit. Which client is best to assigned to an RN who has floated from the surgery unit?
A. A client with infected partial-thickness back and chest burns who has a dressing scheduled.
B. A client who has just been admitted with burns over 30% of the body after a warehouse fire.
C. A client with full-thickness burns on both arms who needs assistance in positioning hand splints.
D. A client who requires discharge teaching about nutrition and wound care after having skin grafts.
16. A client sustained burns on the back. These areas appear dry, blotchy cherry red, blistering, doesn’t blanch, no capillary refill and reduced or absent sensation. This type of burn depth is classified as?
A. Superficial partial-thickness burn.
B. Superficial dermal.
C. Deep partial-thickness burn.
D. Full-thickness burn.
17. Which of the following refers to a wound covering brought about by the donated human cadaver skin provided by the skin bank?
18. A client is being discharged today after undergoing autografting. What would the nurse include in the discharge instructions?
A. Refrain from using splints.
B. Avoid smoking.
C. Exposed the site to sunlight.
D. Encourage weight-bearing exercise.
19. A client is prescribed by the physician to undergo an escharotomy. Which of the following statements made by the nurse is true regarding this procedure?
A. “It is the surgical removal of a thin layer of the client’s own unburned skin.”
B. “A lengthwise incision is made through the burn eschar to relieve vasodilation.”
C. “It is performed at the bedside and without anesthesia.”
D. “It is the application of topical enzyme agents directly to the wound, and these agents digest necrotic collagen tissue”.
20. Rehabilitation is the final phase of the burn care. Which of the following are the goals during this phase? Select all that apply
A. Provide emotional support.
B. Prevent hypovolemic shock.
C. Promote wound healing and proper nutrition.
D. Fluid replacement.
E. Help the client in gaining optimal physical functioning.
Answers and Rationale
Here are the answers and rationale for the NCLEX quiz.
1. Answer: B. 2, 3, 5, 4,1
A pain medication is administered prior the dressing change since the type of burn will be painful during the procedure. Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Lastly, cover the wound using a sterile dressing.
2. Answer: D. Amitriptyline (Elavil) 50 mg PO.
- Options A, B, and C: All health facility practice double checking of medications prior administration, Of all the medications given, Amitriptyline is the most important to double check with another licensed nurse.
3. Answer: C. Urine output.
Of all the options, Urine output is the most reliable indicator for determining the adequacy of fluid resuscitation.
4. Answer: C. A client who has just arrived from the emergency department with burns on the neck and chest.
Burns of the neck and chest are associated with inflammation and swelling of the airway. Hence this patient requires the most immediate attention.
5. Answer: C. Intravenous.
For clients with major burns, the intravascular route is the preferred choice of medicine administration.
- Options A and B: An extensive burn injury causes damage to the muscle and subcutaneous area.
- Option D: Due to the burn injury, the gastrointestinal tract will have decreased perfusion hence relief of pain will not be experienced.
6. Answer: B. Confusion.
Signs and Symptoms of carbon monoxide levels between 21-40% (moderate poisoning) include hypotension, tachycardia, headache, drowsiness, confusion, nausea, and vomiting.
- Options A and D: Carbon monoxide levels of 41% to 60% result in seizure and coma.
- Option C: Carbon monoxide levels of 11% to 20% result in flushing.
7. Answer: A. 36%.
Based on the rule of nines, with posterior trunk equals 18%, right arm equals 9%, and left posterior leg equals 9%. Therefore, a total of 36%.
8. Answer: A. Oxygen via a tight fitting, non-rebreather face mask at 100% concentration.
If an inhalation injury is suspected, management includes the administration of oxygen via a tight fitting, non-rebreather face mask at 100% concentration. This is prescribed until carboxyhemoglobin levels in the blood fall below 15%.
9. Answer: D. All of the above.
Following fasciotomy, the nurse should assess pulses, color, sensation, and movement of the affected extremity as well as bleeding.
10. Answer: A. Elevation and immobilization of the affected leg.
Autograft placed on the lower extremity requires elevation and immobilization for at least 3-7days. This period of immobilization allows the autograft time to adhere to the wound bed.
11. Answer: B. A 40-year-old with partial thickness leg burns which has a temperature of 101.9°F and a blood pressure of 89/48 mm Hg.
The client’s vital signs indicate that life-threatening complications of sepsis may be developing.
12. Answer: B. Increased hematocrit levels.
The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours following the injury. During this phase, there is an elevation of the hematocrit levels due to hemoconcentration from the large fluid shifts
- Option A: Blood pressure is decreased due to the shifting of fluids.
- Option C: Pulse rate is higher than normal.
- Option D: Initially, blood is shunted away from the kidneys, resulting in low urine output.
13. Answer: D. Wearing gloves and a gown only when giving direct care to the client.
- Option A: Thorough handwashing is performed before and after each contact with the burn-injured client.
- Option B: Protective garbs such as mask, gloves, cap, shoe covers, gowns, and a plastic apron need to be worn when having a direct contact with the client.
- Option C: Sterile sheets and linen are used due to the high risk for infection.
14. Answer: A. Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour.
The client’s urine output indicates inadequate fluid resuscitation. Hence the physician would order an increase amount of lactated Ringer’s solution administered hourly.
- Option B: Blood transfusion is not used for fluid resuscitation therapy unless there is an indication of a low hemoglobin level.
- Option C: Diuretic works by removing circulating volume, thereby further compromising the inadequate tissue perfusion.
- Option D: Dextrose in water will only maintain fluid balance since it is an isotonic solution, therefore will not be helpful in this situation.
15. Answer: A. A client with infected partial-thickness back and chest burns who has a dressing scheduled.
Familiarity with the dressing change and practice of sterility by a nurse from the surgery unit will be appropriately used during the float in the burn unit.
- Options B, C, and D: Admission assessment, splinting and discharge teaching require expertise in caring for burn patients.
16. Answer: C. Deep partial-thickness burn.
Deep partial-thickness burn: blistering, dry, blotchy cherry red, doesn’t blanch, no capillary refill and reduced or absent sensation. Generally, heals in 3-6 weeks, but scar formation results and skin grafting may be required.
- Option A: Superficial partial-thickness: red, glistening, pain, absence of blisters and brisk capillary refill. Not life-threatening and normally heal within a week, without scarring.
- Option B: pale pink or mottled appearance with associated swelling and small blisters. With a wet, shiny, and weeping surface is also a characteristic. Brisk capillary refill.
- Option D: Full-thickness: dry, white or black, no blisters, absent capillary refill and absent sensation. Requires surgical repair and grafting.
17. Answer: B. Homograft.
- Option A: Autograft: Skin taken from a remote unburned area of client’s own body.
- Options C and D: Xenograft or Heterograft: graft of tissue taken from a donor of one species and grafted into a recipient of another species.
18. Answer: B. Avoid smoking.
Avoiding smoking since it can decrease the blood supply to the newly graft recipient bed interface, and the chance of graft failure increases.
- Option A: The aPTT determines the effects of heparin therapy.
19. Answer: C. “It is performed at the bedside and without anesthesia”.
Escharotomy is performed at the bedside and without anesthesia since nerve endings have been destroyed by the burn injury.
- Option A refers to skin autograft.
- Option B Escharotomy involves making a lengthwise incision through the burn eschar to relieve vasoconstriction.
- Option D refers to enzymatic debridement.
20. Answer: A. Provide emotional support., C. Promote wound healing and proper nutrition., E. Help the client in gaining optimal physical functioning.,
- Options B and D belongs to the main goal during the resuscitative phase.
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