FULL-TEXT: Burns & Burn Injury (100 Questions)

This is the full-text copy of the 100-item quiz Burns & Burn Injury NCLEX Practice Questions.
Use this page to print a copy of the quiz or export it via PDF.

CREATING PDF. For most modern browsers like Chrome, Safari, Firefox, Edge, you can simply click on File> Print > Save as PDF to create a PDF version of this page.

For more quizzes, please visit Nursing Test Bank and Nursing Practice Questions for Free.

Burns NCLEX Question and Burn Injury Nursing Management Quiz #1 (20 Items)

NURSESLABS-BURNINJURY-01-001

A 23-year-old male 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?

A. How to maintain home smoke detectors
B. Joining a community reintegration program
C. Learning to perform dressing changes
D. Options available for scar removal

Correct Answer: C. Learning to perform dressing changes

Teaching the patient and his family to perform dressing changes is critical for the goal of progression towards independence. Proper management of burn injury through proper dressing changes helps prevent wound deterioration. Encouragement of the patient and his family members in participating in dressing changes and wound care helps prepare for the patient’s eventual discharge and home care needs. All other choices (below) are important during the rehabilitation stage but dressing changes is a priority.

Option A: Teach on the importance of installing and maintaining smoke detectors on every level of the home and changing batteries periodically to help prevent fires.
Option B: Surviving a burn injury has a tremendous psychological impact on the patient and family. The nurse plays a key role in helping the patient adapt. Providing referrals to social services and counseling helps the patient during his rehabilitation phase.
Option D: Discussion about burn reconstruction treatment after the scars have healed or matured is usually discussed after the first few years after injury. This option is often used to “improve both the function and the cosmetic appearance of burn scars”.

NURSESLABS-BURNINJURY-01-002

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?

A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).

Correct Answer: A. Start intravenous fluids.

Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Administration of fluids can treat this problem. For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour.

Option C: Following a severe burn injury, significant hematologic changes occur that are reflected in complete blood count (CBC) measurements. A 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.
Option B: Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action. Carefully check pulses in any extremity with circumferential burns. These burns can act as tourniquets as burn-associated edema begins, leading to compartment syndrome.
Option D: In patients with extensive burns, it is sometimes a challenge to monitor the ECG, because the lack of natural skin and application of protective ointments prevent the adherence of the ECG discs.

NURSESLABS-BURNINJURY-01-003

A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first?

A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position

Correct Answer: D. Place the client in an upright position

Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out.

Option A: Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lungs. However, digoxin has the potential to cause bradyarrhythmias.
Option B: Chest physiotherapy will not get rid of the fluid and is not a priority among the choices. Chest physiotherapy is only applicable during the post-burn management of the patient.
Option C: Monitoring urine output is important. However, it is not an immediate intervention. Use the patient’s urine output and physiologic response to determine if the volume is adequate for resuscitation.

NURSESLABS-BURNINJURY-01-004

How will the nurse position a client with a burn wound to the posterior neck to prevent contractures?

A. Have the client turn the head from side to side.
B. Keep the client in a supine position without the use of pillows.
C. Keep the client in a semi-Fowler’s position with her or his arms elevated.
D. Place a towel roll under the client’s neck or shoulder.

Correct Answer: A. Have the client turn the head from side to side.

Deformities and contractures can often be prevented by proper positioning. Maintaining proper body alignment when the patient is in bed is vital. 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. This movement is what would prevent contractures from occurring.

Option B: The client should not only be in a supine position but there should be a movement to avoid contractures. Splinting and proper positioning will also help achieve the prevention of contractures. As a matter of importance, movement should be incorporated into the patient’s daily routine from their inception to the hospital.
Option C: The burns are in the client’s posterior neck. Performing active or passive range of motion (ROM) exercises, depending on the patient’s level of consciousness is crucial in the prevention of these complications.
Option D: Placing a towel roll under the neck might not help prevent contractures. Immobilization is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an antideformity position.

NURSESLABS-BURNINJURY-01-005

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?

A. Documenting the findings
B. Loosening any dressings on the chest
C. Raising the head of the bed
D. Preparing for intubation

Correct Answer: D. Preparing for intubation

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the 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.

Option A: Documentation of findings should be done after the interventions. There may be only a small window of opportunity to easily place an ET tube because edema from burn shock may obstruct the airway.
Option B: Loosening any dressings on the chest should be done right after the assessment of wheezes. If there is edema or evidence of burn in the upper airways, assessment for whether an endotracheal (ET) tube is needed to maintain the airway should be done immediately.
Option C: The head of the bed should be flat to prepare for intubation. Emergency airway intubation should be done immediately after assessment to avoid complete obstruction of the airway due to edema.

Questions and rationale from Nurseslabs.com Feel free to print or share and link back to us! For more practice questions, please visit our Nursing Test Bank [https://nurseslabs.com/nursing-test-bank]

NURSESLABS-BURNINJURY-01-006

Ten hours after the client with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse’s best action?

A. Documents the finding
B. Obtains a family history of diabetes
C. Repeats the glucose measurement
D. Stop IV fluids containing dextrose

Correct Answer: A. Documents the finding

Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases 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.

Option B: 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 secondary assessment shouldn’t begin until the primary assessment is complete; resuscitative efforts are underway; and lines, tubes, and catheters are placed.
Option C: The glucose level is not high enough to warrant retesting. A variety of laboratory tests will be needed within the first 24 hours of a patient’s admission (some during the initial resuscitative period and others after the patient is stabilized).
Option D: The cause of her elevated blood glucose is not the IV fluid. Rapid and aggressive fluid resuscitation is needed to replace intravascular volume and maintain end-organ perfusion.

NURSESLABS-BURNINJURY-01-007

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?

A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full-thickness deep

Correct Answer: C. Partial-thickness deep

Deep partial-thickness burns are pink or red in color, swollen, painful, with blisters that may ooze a clear fluid. Deep partial-thickness (second-degree) involves the deeper dermis. Healing occurs in 3 to 8 weeks with scarring present.

Option A: Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation.
Option B: The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is red; without blisters and pain present. Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.
Option D: Blisters are not seen with full-thickness burns and are rarely seen with deep partial-thickness burns. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

NURSESLABS-BURNINJURY-01-008

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?

A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial

Correct Answer: A. Full-thickness

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. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

Option B: Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.
Option C: Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.
Option D: Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.

NURSESLABS-BURNINJURY-01-009

The client has experienced an electrical injury of the lower extremities. Which is the priority assessment data to obtain from this client?

A. Current range of motion in all extremities
B. Heart rate and rhythm
C. Respiratory rate and pulse oximetry reading
D. Orientation to time, place, and person

Correct Answer: B. Heart rate and rhythm

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. It is also important to obtain the patient’s cardiac history, including any history of prior arrhythmias.

Option A: Range of motion is also 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.
Option C: The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Any patient that was in contact with a high voltage source should have continuous cardiac monitoring during evaluation.
Option D: These patients are specifically at risk for cardiac damage if the path of the current traversed the heart. One may also consider CT imaging of the head if the patient has altered mental status or associated head trauma from a fall or being thrown in a blast.

NURSESLABS-BURNINJURY-01-010

A 35-year-old male client was admitted due to severe burns around his right hip. Which position is most important to use to maintain the maximum function of this joint?

A. Hip maintained in 30-degree flexion
B. Hip at zero flexion with leg flat
C. Knee flexed at 30-degree angle
D. Leg abducted with a foam wedge

Correct Answer: B. Hip at zero flexion with leg flat

The 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.

Option A: Anti-contracture positioning and splinting must start from day one and may continue for many months post-injury. Legs should be positioned in a neutral position ensuring that the patient is not externally rotating at the hips.
Option C: Patients rest in a position of comfort; this is generally a position of flexion and also the position of contracture. Without ongoing advice and help with positioning, the patient will continue to take the position of contracture and can quickly lose ROM in multiple joints. Once contracture starts to develop it can be a constant battle to achieve full movement, so preventative measures to minimize contracture development are necessary.
Option D: Splinting helps maintain anti-contracture positioning particularly for those patients experiencing a great deal of pain, difficulty with compliance, or with burns in an area where positioning alone is insufficient. If the injured site is over joint surfaces, special precautions should be taken to identify all possible joint contractures.

NURSESLABS-BURNINJURY-01-011

The client with burns is drooling and having difficulty swallowing. Which action will the nurse take first?

A. Assesses level of consciousness and pupillary reactions.
B. Ascertain the time food or liquid was last consumed.
C. Auscultates breath sounds over the trachea and mainstem bronchi.
D. Measures abdominal girth and auscultates bowel sounds.

Correct Answer: C. Auscultates breath sounds over the trachea and mainstem bronchi.

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.

Option A: Knowing the level of consciousness is important to assess oxygenation to the brain. In most cases, neurologic status won’t be altered in the early stages of burn injury. Use the Glasgow Coma Scale to trend the patient’s neurologic status throughout resuscitation.
Option B: 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 air exchange is the most important intervention at this time.
Option D: Measuring abdominal girth is not relevant in this situation. If there is edema or evidence of burn in the upper airways, assess whether an endotracheal (ET) tube is needed to maintain the airway.

NURSESLABS-BURNINJURY-01-012

A 22-year-old female client with a full-thickness burn is being discharged to home after a month in the hospital. Her wounds are minimally opened and she will be receiving home care. Which nursing diagnosis has the highest priority?

A. Acute Pain
B. Deficient Diversional Activity
C. Impaired Adjustment
D. Imbalanced Nutrition: Less than Body Requirements

Correct Answer: C. Impaired Adjustment

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 her pre-burn 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.

Option A: By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
Option B: Diversional activity for pain is applicable during the intermediate phase of the burn injury. Provide diversional activities appropriate for age and condition. This helps lessen concentration on pain experience and refocus attention.
Option D: Imbalanced nutrition is more appropriate during the emergent and intermediate phases of the burn injury. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As the burn wound heals, the percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.

NURSESLABS-BURNINJURY-01-013

The client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse’s best response?

A. “Tagamet will stimulate intestinal movement.”
B. “Tagamet can help prevent hypovolemic shock.”
C. “This will help prevent stomach ulcers.”
D. “This drug will help prevent kidney damage.”

Correct Answer: C. “This will help prevent stomach ulcers.”

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.

Option A: Gastrointestinal stimulants are drugs that increase motility of the gastrointestinal smooth muscle, without acting as a purgative. These drugs have different mechanisms of action but they all work to move the contents of the gastrointestinal tract faster.
Option B: Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.” Four mL lactated ringers solution × percentage total body surface area (%TBSA) burned × patient’s weight in kilograms = total amount of fluid given in the first 24 hours.
Option D: Cimetidine does not prevent kidney damage. Acute renal failure is one of the major complications of burns and it is accompanied by a high mortality rate. Most renal failures occur either immediately after the injury or at a later period when sepsis develops.

NURSESLABS-BURNINJURY-01-014

A 12-year-old male with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?

A. “With reconstructive surgery, you can look the same.”
B. “We can remove the scars with the use of a pressure dressing.”
C. “You will not look exactly the same.”
D. “You shouldn’t start worrying about your appearance right now.”

Correct Answer: C. “You will not look exactly the same.”

Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Denial may be prolonged and be an adaptive mechanism because the patient is not ready to cope with personal problems.

Option A: Be realistic and positive during treatments, in health teaching, and in setting goals within limitations. This enhances trust and rapport between patient and nurse.
Option B: Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes. Provide hope within the parameters of the individual situation; do not give false reassurance. This promotes a positive attitude and provides opportunities to set goals and plan for the future based on reality.
Option D: Acknowledge and accept the expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial. Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push the patient before he is ready to deal with the situation.

NURSESLABS-BURNINJURY-01-015

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?

A. Continuing to monitor the client.
B. Increasing the temperature in the room.
C. Increasing the rate of the intravenous fluids.
D. Preparing to do a workup for sepsis.

Correct Answer: D. Preparing to do a workup for sepsis.

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.

Option A: Continuing just to monitor the situation can lead to septic shock. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.
Option B: 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.
Option C: Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action. Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on the extent of injury, amount of urinary output, and weight.

NURSESLABS-BURNINJURY-01-016

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?

A. “As soon as he finishes his antibiotic prescription.”
B. “As soon as his albumin level returns to normal.”
C. “When fluid remobilization has started.”
D. “When the burn wounds are closed.”

Correct Answer: D. “When the burn wounds are closed.”

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.

Option A: Even after the course of treatment of antibiotics, the patient is still at risk for infection if the wounds remain open. Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.
Option B: Albumin levels are monitored if there is significant edema. Implement appropriate isolation techniques as indicated. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
Option C: Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.

NURSESLABS-BURNINJURY-01-017

The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan?

A. Have chimneys swept every 2 years.
B. Keep a smoke detector in each bedroom.
C. Use space heaters instead of gas heaters.
D. Use carbon monoxide detectors only in the garage.

Correct Answer: B. Keep a smoke detector in each bedroom.

Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom has a separate smoke detector. Test smoke alarms every month. If they’re not working, change the batteries.

Option A: If there is a fireplace, make sure the chimney is checked and cleaned by a professional once a year. Use a metal or glass screen that is large enough to prevent escaping embers. Make sure home heating sources are clean and in working order. Many home fires are started by poorly maintained furnaces or stoves, cracked or rusted furnace parts, or chimneys with creosote buildup.
Option C: Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby. Make sure to always keep anything that gives off heat at least 3 feet away from flammable materials or items. Heating equipment, like space heaters, are involved in 1 of every 6 home fires. Furthermore, 1 in every 5 home fire deaths and half of all fires caused by home heating occur between December and February.
Option D: Carbon monoxide detectors should also be placed inside the house, not only in the garage. A person can be poisoned by a small amount of CO over a longer period of time or by a large amount of CO over a shorter amount of time.

NURSESLABS-BURNINJURY-01-018

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?

A. Applies silver sulfadiazine (Silvadene) ointment
B. Covers the area with an elastic wrap
C. Places a synthetic dressing over the area
D. Removes loose nonviable tissue

Correct Answer: D. Removes loose nonviable tissue

The first step in this process is removing exudates and necrotic tissue. Burn patients are at high risk for infection, especially drug-resistant infection, which often results in significantly longer hospital stays, delayed wound healing, higher costs, and higher mortality

Option A: Since the adoption of topical antibiotics, such as mafenide in the 1960s and silver sulfadiazine in the 1970s, and of early excision and grafting in the 1970s and thereafter, systemic infections and mortality have consistently decreased. However, Gram-positive and Gram-negative bacterial infections still remain one of the most common causes of mortality following burn injury.
Option B: While many factors must be considered in dressing selection, the goals in selecting the most appropriate dressing should include providing protection from contamination (bacterial or otherwise) and from physical damage, allowing gas exchange and moisture retention, and providing comfort to enhance functional recovery.
Option C: The selection of an appropriate dressing depends on several factors, including depth of burn, condition of the wound bed, wound location, desired moisture retention and drainage, required frequency of dressing changes, and cost.

NURSESLABS-BURNINJURY-01-019

The nurse should teach the community that a minor burn injury could be caused by what common occurrence?

A. Chimney sweeping every year
B. Cooking with a microwave oven
C. Use of sunscreen agents
D. Use of space heaters

Correct Answer: D. Use of space heaters

Minor burns are common occurrences. The use of space heaters can cause a fire if clothing, bedding, and other flammable objects are near them. Make sure to always keep anything that gives off heat at least 3 feet away from flammable materials or items.

Option A: Chimneys should be swept each year to prevent creosote build-up and resultant fire. If there is a fireplace, make sure the chimney is checked and cleaned by a professional once a year. Use a metal or glass screen that is large enough to prevent escaping embers.
Option B: Burn injuries do not commonly occur from microwave cooking, but rather when taking food from it. Thermal burns are skin injuries caused by excessive heat, typically from contact with hot surfaces, hot liquids, steam, or flame. Most burns are minor and patients can be treated as outpatients or at local hospitals.
Option C: Lastly, sunscreen agents are recommended to prevent sunburn. A broad-spectrum sunscreen with an SPF of at least 30 should be applied 30 minutes before sun exposure and every 90 minutes after that.

NURSESLABS-BURNINJURY-01-020

The nurse uses topical gentamicin sulfate (Garamycin) on a client’s burn injury. Which laboratory value will the nurse monitor?

A. Creatinine
B. Red blood cells
C. Sodium
D. Magnesium level

Correct Answer: A. Creatinine

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. In burn patients, the systemic absorption of topical gentamicin may be enhanced, and one should be watchful for the potential repercussions.

Option B: Topical gentamicin will not affect the red blood cell count. The gentamicin is prone to accumulate in the renal proximal tubular cells and can cause damage. Hence, mild proteinuria and reduction of the glomerular filtration rate are potential consequences of gentamicin use, achieving 14% of gentamicin users in a review.
Option C: Topical gentamicin will not affect sodium. In cases of renal impairment, dosing adjustment should be made based on the glomerular filtration rate (GFR); for high-dose, extended interval dosing approach, the dose can be preserved, but the interval between doses should increase in line with GFR decrease.
Option D: Topical gentamicin will not affect the magnesium level. Renal function should be evaluated twice-weekly in patients without previous renal disease through serum creatinine and blood urea nitrogen. Periodic microscopic urinalysis is also vital to detect proteinuria and casts, which may indicate kidney injury.

Burns NCLEX Question and Burn Injury Nursing Management Quiz #2 (20 Items)

NURSESLABS-BURNINJURY-02-001

The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?

A. Administer the prescribed tetanus toxoid vaccine.
B. Assess wounds for signs of infection.
C. Encourage the client to cough and breathe deeply.
D. Wash hands on entering the client’s room.

Correct Answer: D. Wash hands on entering the client’s room.

Infection can occur when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations. Emphasize and model good handwashing techniques for all individuals coming in contact with the patient.

Option A: Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
Option B: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention.
Option C: Although all the interventions listed can help reduce the risk of infection, hand washing is the most effective technique for preventing infection transmission. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn.

NURSESLABS-BURNINJURY-02-002

Three days after a burn injury, the client develops a temperature of 100° F, a white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?

A. Acute phase of the injury
B. Autodigestion of collagen
C. Granulation of burned tissue
D. Wound infection

Correct Answer: D. Wound infection

Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.

Option A: These symptoms will not be seen in the acute phase of the injury. Assess and document size, color, depth of wound, noting necrotic tissue and condition of the surrounding skin.
Option B: Autodigestion of collagen will not increase the body temperature or cause foul-smelling wound discharge. Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.
Option C: Granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge. Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.

NURSESLABS-BURNINJURY-02-003

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse’s best action?

A. Administers a laxative
B. Documents the finding
C. Increases the IV flow rate
D. Repositions the client onto the right side

Correct Answer: B. Documents the finding

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time.

Option A: Do not give the patient laxative. The emergent phase starts with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of patient care involves maintaining an adequate airway and treating the patient for burn shock.
Option C: Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24–72 hr after burn injury. Fluid replacement formulas partly depend on admission weight and subsequent changes.
Option D: Maintain proper body alignment with supports or splints, especially for burns over joints. This promotes functional positioning of extremities and prevents contractures, which are more likely over joints.

NURSESLABS-BURNINJURY-02-004

What intervention will the nurse implement to reduce a client’s pain after a burn injury?

A. Administering morphine 4 mg intravenously.
B. Administering hydromorphone (Dilaudid) 4 mg intramuscularly.
C. Applying ice to the burned area
D. Avoiding tactile stimulation

Correct Answer: A. Administering morphine 4 mg intravenously.

Drug therapy for pain management requires opioid and nonopioid analgesics. The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect.

Option B: The IV route is used because of problems with absorption from the muscle and stomach. Concerns of patient addiction or doubts regarding the degree of pain experienced are not valid during the emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.
Option C: For the client to avoid shivering, the room must be kept warm and heat should be applied. Maintain comfortable environmental temperature, provide heat lamps, heat-retaining body coverings. Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
Option D: Tactile stimulation can be used for pain management. Provide basic comfort measures: massage of uninjured areas, frequent position changes. This promotes relaxation and reduces muscle tension and general fatigue.

NURSESLABS-BURNINJURY-02-005

What statement indicates the client needs further education regarding skin grafting (allografting)?

A. “Because the graft is my own skin, there is no chance it won’t ‘take.'”
B. “For the first few days after surgery, the donor sites will be painful.”
C. “I will have some scarring in the area when the skin is removed for grafting.”
D. “I am still at risk for infection after the procedure.”

Correct Answer: A. “Because the graft is my own skin, there is no chance it won’t ‘take.'”

Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Graft survival depends on the diffusion of nutrients and oxygen from the wound bed known as imbibition. Inosculation then follows when the blood vessels of the graft and from the wound bed grow together to make end-to-end contact. Lastly, neovascularization occurs when new blood vessels grow from the wound bed into the graft.

Option B: The donor sites will be painful after the surgery. Silicone gel sheets, along with pressure dressings, have shown a dramatic decrease in pain, pruritus, and scar thickness six months after burn injury.
Option C: There can be scarring in the area where the skin is removed for grafting. Burn scars are a common occurrence after skin grafting and can cause anxiety, depression, pain, itching, altered pigmentation, temperature intolerance, and decreased range of motion secondary to scar contracture. Scar formation is propagated by deficiencies in the biosynthetic and tissue degradation pathway during wound healing.
Option D: The client is still at risk for infection. Early failure of graft survival is attributable to seroma and hematoma formation, which lifts the graft off the wound bed, preventing imbibition. Other factors that lead to graft failure include shearing forces, edematous tissue, and infected tissue.

NURSESLABS-BURNINJURY-02-006

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by auto contamination?

A. Avoiding sharing equipment such as blood pressure cuffs between clients.
B. Changing gloves between wound care on different parts of the client’s body.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.

Correct Answer: B. Changing gloves between wound care on different parts of the client’s body.

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.

Option A: Although all techniques listed can help reduce the risk of infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent auto contamination. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
Option C: Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). This identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
Option D: Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. This prevents cross-contamination and reduces the risk of acquired infection.

NURSESLABS-BURNINJURY-02-007

Which assessment finding assists the nurse in confirming inhalation injury?

A. Brassy cough
B. Decreased blood pressure
C. Nausea
D. Headache

Correct Answer: A. Brassy cough

Brassy cough and wheezing are some signs seen with inhalation injury. Damage to airway tissue causes increased mucus production, edema, denudation of epithelium, and mucosal ulceration and hemorrhage. Obstruction of airflow is often the effect caused by tissue edema narrowing the passageways and mucus/blood/fluid impeding airflow.

Option B: Patients with carbon monoxide poisoning may exhibit hypotension. As carboxyhemoglobin (COHgb) levels rise, the cerebral blood vessels dilate, and both coronary blood flow and capillary density increases. Cardiac effects, especially ventricular arrhythmias occur. Ventricular arrhythmias are implicated as the cause of death most often in CO poisoning.
Option C: Most commonly, patients with carbon monoxide poisoning will present with headache (more than 90%), dizziness, weakness, and nausea. Patients may be tachycardic and tachypneic.
Option D: Patients may have systemic symptoms like a headache, delirium, hallucinations, and may even be comatose. Many different etiologies may cause changes in mental status including hypoxia, hypercarbia, or asphyxiant exposure (carbon monoxide, hydrogen cyanide). But headaches can also be seen with carbon monoxide poisoning.

NURSESLABS-BURNINJURY-02-008

Which finding indicates that fluid resuscitation has been successful for a client with a burn injury?

A. Hematocrit = 60%
B. Heart rate = 130 beats/min
C. Increased peripheral edema
D. Urine output = 50 mL/hr

Correct Answer: D. Urine output = 50 mL/hr

The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate to more normal levels, as well as laboratory values. This phase occurs on days 1-3 and requires an accurate fluid resuscitation and thorough evaluation for other injuries and comorbid conditions.

Option A: Hematocrit can indirectly reflect the resuscitation effect in the burn shock stage. Whether hematocrit level can be lowered to 0.45-0.50 during the first 24 hours after burn may be an important index for evaluation of fluid resuscitation effect in the early shock stage after severe burn.
Option B: The average daily heart rate was elevated in burn patients up to two years post-burn. Heart rate was elevated despite any afforded resuscitative efforts. While research data are up to two years post-injury, the heart rate of severely burned children was still 120% of predicted compared to normal values for children.
Option C: Swelling tends to occur soon after injury and generally decreases after 48–72 hours, although this timescale can vary. The extent and location of the swelling will depend on how the burn was caused and the location and depth of the burn injury. It is very important that the swelling is reduced as soon as possible.

NURSESLABS-BURNINJURY-02-009

Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance?

A. Allowing family members to change his dressings
B. Discussing future surgical reconstruction
C. Performing his own morning care
D. Wearing the pressure dressings as ordered

Correct Answer: C. Performing his own morning care

Indicators that the client with a burn injury has a positive perception of his appearance include the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image.

Option A: Encourage the patient and SO to view wounds and assist with care as appropriate. This promotes acceptance of the reality of injury and of change in body and image of self as different.
Option B: Discussing future reconstruction would not indicate a positive perception of appearance. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.
Option D: Wearing the dressing will assist in decreasing complications, but will not increase self-perception. However, give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals. Words of encouragement can support the development of positive coping behaviors.

NURSESLABS-BURNINJURY-02-010

Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury?

A. “It is normal to feel depressed.”
B. “I will be able to go back to work immediately.”
C. “I will not feel anger about my situation.”
D. “Once I get home, things will be normal.”

Correct Answer: A. “It is normal to feel depressed.”

During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems.

Option B: Assist the patient and the family to express their feelings of grief and guilt. The patient and the family may initially be most concerned about the patient’s death and/or feel guilty, believing that in some way they could have prevented the incident.
Option C: Acknowledge and accept the expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial. Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push the patient before ready to deal with the situation.
Option D: Assist the patient to identify the extent of actual change in appearance and body function. Feelings of grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

NURSESLABS-BURNINJURY-02-011

Which finding is characteristic during the emergent period after a deep full-thickness burn injury?

A. Blood pressure of 170/100 mm Hg
B. Foul-smelling discharge from wound
C. Pain at site of injury
D. Urine output of 10 mL/hr

Correct Answer: D. Urine output of 10 mL/hr

During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreased. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation.

Option A: Blood pressure is usually low. During this inflammatory response, there is fluid loss that can cause a sharp and potentially deadly drop in blood pressure known as shock.
Option B: A foul-smelling discharge does not occur during the emergent phase. Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry.
Option C: Pain does not occur with deep full-thickness burns. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

NURSESLABS-BURNINJURY-02-012

Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain?

A. Decreased Tissue Perfusion
B. Disturbed Body Image
C. Risk for Disuse Syndrome
D. Risk for Ineffective Breathing Pattern

Correct Answer: A. Decreased Tissue Perfusion

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy.

Option B: Disturbed body image can develop. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.
Option C: Disuse syndrome can develop. Risk for disuse syndrome may be related to the physiological changes brought about by physical inactivity. These changes may include a decrease in muscle strength, limited joint movement, and loss of bone density. However, this is not a priority diagnosis at this time.
Option D: Chemical burns do not cause inhalation injury and a disrupted breathing pattern. The most common findings represent structural changes to the tissue directly affected, for example, the eye, oral mucosa, skin, esophagus, and lower intestinal system, especially the stomach and pylorus, respiratory system, among others.

NURSESLABS-BURNINJURY-02-013

Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately?

A. Arterial pH, 7.32
B. Hematocrit, 52%
C. Serum potassium,7.5 mmol/L (mEq/L)
D. Serum sodium, 131 mmol/L (mEq/L)

Correct Answer: C. Serum potassium,7.5 mmol/L (mEq/L)

The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk of experiencing severe cardiac dysrhythmias and death.

Option A: Acid-base studies were carried out on 76 consecutive burn patients admitted within 36 hours of injury. Admission blood pH and base excess (BE) values all decreased in a linear relationship to the extent of the burn. Blood Pco-2 changes were unrelated to the extent of the burn. Significant acidosis developed within 2 hours of burn injury.
Option B: The hematocrit (Hct) is the percentage of the volume of the whole blood that is made up of red blood cells. In burns, the patient has lost a lot of fluid from leaky blood vessels. There are more red cells than fluid so the hematocrit is high.
Option D: Serum sodium is abnormal, but not to the same degree of severity, and would be expected in the emergent phase after a burn injury. Severe cutaneous injuries such as burn injuries and blast injuries result in the loss of both water and sodium. For burn patients, hypernatremia that occurs within a few days of injury may be associated with increased risk of death.

NURSESLABS-BURNINJURY-02-014

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury?

A. Allowing the client to eat whenever he or she wants.
B. Beginning parenteral nutrition high in calories.
C. Limiting calories to 3000 kcal/day.
D. Providing a low-protein, high-fat diet.

Correct Answer: A. Allowing the client to eat whenever he or she wants.

Clients should request food whenever they think that they can eat, not just according to the hospital’s standard meal schedule. Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. This provides the patient or SO a sense of control; enhances participation in care and may improve intake.

Option B: Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. Total parenteral nutrition (TPN) maintains nutritional intake and meets metabolic needs in presence of severe complications or sustained esophageal or gastric injuries that do not permit enteral feedings.
Option C: Clients who can eat solid foods should ingest as many calories as possible. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As the burn wound heals, the percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.
Option D: The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Refer to a dietitian or nutrition support team. This may be useful in establishing individual nutritional needs (based on weight and body surface area of injury) and identifying appropriate routes.

NURSESLABS-BURNINJURY-02-015

Which statement best exemplifies the client’s understanding of rehabilitation after a full-thickness burn injury?

A. “I am fully recovered when all the wounds are closed.”
B. “I will eventually be able to perform all my former activities.”
C. “My goal is to achieve the highest level of functioning that I can.”
D. “There is never full recovery from a major burn injury.”

Correct Answer: C. “My goal is to achieve the highest level of functioning that I can.”

Although a return to pre-burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

Option A: The final stage in caring for a patient with a burn injury is the rehabilitative stage. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
Option B: Early compliance is essential to ensure the best possible long-term outcome and also to ease pain and assist with exercise regimes. Patients need to adhere to a positioning regime in the early stages of healing and this takes teamwork and dedication.
Option D: Rehabilitation of burns patients is a continuum of active therapy starting from admission. There should be no delineation between an ‘acute phase’ and a ‘rehabilitation phase’ as this idea can promote the inequality of secondary disjointed scar management and/or functional rehabilitation teams.

NURSESLABS-BURNINJURY-02-016

Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment?

A. “My facial scars should be less severe with the use of this mask.”
B. “The mask will help protect my skin from sun damage.”
C. “This treatment will help prevent infection.”
D. “Using this mask will prevent scars from being permanent.”

Correct Answer: A. “My facial scars should be less severe with the use of this mask.”

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Hypertrophic burn scars pose a challenge for burn survivors and providers. In many cases, they can severely limit a burn survivor’s level of function, including work and recreational activities.

Option B: Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy (PGT).
Option C: The pressure garment will not alter the risk of infection. At present, PGT is the standard first-line therapy for hypertrophic burn scars in many centers due to its non-invasive characteristics and presumed desirable treatment effects with few associated complications.
Option D: Scars will still be present. This treatment modality continues to be a clinically accepted practice. It is the most common therapy used for the treatment and prevention of abnormal scars after burn injury particularly in North America, Europe and Scandinavia where it is considered routine practice and regarded as the preferred conservative management with reported thinning and better pliability ranging from 60% to 85%.

NURSESLABS-BURNINJURY-02-017

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s initial action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

Correct Answer: B. Loosen the dressing

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status. Generally, it is recommended that pressure should be maintained between 20 and 30 mm Hg, which is above capillary pressure but less than what would diminish peripheral blood circulation.

Option A: It is unnecessary to administer oxygen. Wearing pressure garments is uncomfortable and challenging; problems with movement, appearance, fit, comfort, swelling of extremities, rashes, and blistering are common; consequently, low compliance with PGT is to be expected.
Option C: The nurse may intervene first. However, monitoring of pressure exerted by pressure garments is currently difficult and time-consuming, and not routinely done and currently, the optimal pressure magnitude for PGT remains unsolved.
Option D: The nurse may loosen the dressing to help the client breathe. Recent evidence suggests that pressure garment therapy is effective for the prevention and/or treatment of abnormal scarring after burn injury but that the clinical benefit is restricted to those patients with moderate or severe scarring.

NURSESLABS-BURNINJURY-02-018

During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level

Correct Answer: D. Increased serum creatinine level

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. Characteristically, gentamicin reaches high concentrations in the renal cortex and the inner ear.

Option A: Gentamicin does not stimulate pain in the wound. The gentamicin is prone to accumulate in the renal proximal tubular cells and can cause damage. Hence, mild proteinuria and reduction of the glomerular filtration rate are potential consequences of gentamicin use, achieving 14% of gentamicin users in a review.
Option B: The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Renal function should be evaluated twice-weekly in patients without previous renal disease through serum creatinine and blood urea nitrogen. Periodic microscopic urinalysis is also vital to detect proteinuria and casts, which may indicate kidney injury.
Option C: The possible hypersensitivity manifestations of gentamicin are urticaria, eosinophilia, delayed-type hypersensitivity reaction (Stevens-Johnson syndrome and toxic epidermal necrolysis), angioedema, and anaphylactic shock. The clinical manifestations should guide the treatment strategy.

NURSESLABS-BURNINJURY-02-019

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

A. Changing gloves between wound care on different parts of the client’s body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.

Correct Answer: A. Changing gloves between wound care on different parts of the client’s body

Option B: Although all techniques listed can help reduce the risk of infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
Option C: Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). This identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
Option D: Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. This prevents cross-contamination and reduces the risk of acquired infection.

NURSESLABS-BURNINJURY-02-020

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month

Correct Answer: C. Myocardial infarction 1 year ago.

Option A: Asthma is a chronic inflammatory disease of the airways, characterized by recurrent episodes of airflow obstruction resulting from edema, bronchospasm, and increased mucus production. Commonly associated with seasonal allergies (allergic rhinitis) and eczema (atopic dermatitis), these three conditions form what is known as the atopic triad.
Option B: The incubation period of an acute hepatitis B virus infection is approximately 12 weeks, with a majority of patients experiencing mild illness and less than 1% experiencing fulminant hepatic failure. After acute infection resolves, the majority of adult patients and a small percentage of infected infants develop antibodies against the hepatitis B surface antigen and end up recovering fully.
Option D: Nephrolithiasis, or kidney stones, is the most common condition affecting the urinary system, affecting about 12% of the world population, with a yearly incidence of 600,000 in America. It is the result of a crystal or crystalline concretion traveling from the kidney through the genitourinary system.

Burns NCLEX Question and Burn Injury Nursing Management Quiz #3 (20 Items)

NURSESLABS-BURNINJURY-03-001

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.

Administer Tramadol (Tramal) 50 mg IV.
Debride the wound of eschar using gauze sponges.
Obtain a sample for wound culture.
Apply silver nitrate ointment.
Cover the wound using a sterile gauze dressing.

The correct order is shown above

Rationale:

Pain medication is administered prior to the dressing change since the type of burn will be painful during the procedure. Opioids may be required initially to control pain, but once first aid measures have been effective non-steroidal anti-inflammatory drugs such as ibuprofen or co-dydramol taken orally will suffice.
Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. It is important to realize that a new burn is essentially sterile, and every attempt should be made to keep it so. The burn wound should be thoroughly cleaned with soap and water or mild antibacterial wash such as dilute chlorhexidine.
Obtain a sample for wound culture. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury
An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Flamazine is silver sulfadiazine cream and is applied topically on the burn wound. It is effective against gram-negative bacteria including Pseudomonas.
Lastly, cover the wound using a sterile dressing. Depending on how healing is progressing, dressing changes thereafter should be every three to five days. If the Jelonet dressing has become adherent, it should be left in place to avoid damage to the delicate healing epithelium. If Flamazine is used it should be changed on alternate days.

NURSESLABS-BURNINJURY-03-002

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?

A. Aloe Vera Relief Burn spray.
B. Silver Sulfadiazine ointment.
C. Omeprazole 20 mg slow IV push.
D. Amitriptyline (Elavil) 50 mg PO.

Correct Answer: D. Amitriptyline (Elavil) 50 mg PO.

Amitriptyline (Elavil) is useful in the management of neuropathic pain following burn injury and since it is an antidepressant if given with a child, utmost precaution is given. The FDA has issued a black box warning regarding the use of amitriptyline in adolescents and young adults (ages less than 24 years). It can increase the risk of suicidal ideation and behavior.

Option A: Omeprazole is indicated for the short-term treatment of peptic ulcer disease in adults where most patients heal within four weeks. Patients with duodenal ulcer disease and H. pylori infection disease that is active for up to one year may benefit from combination therapy that includes omeprazole with clarithromycin, amoxicillin, and metronidazole.
Option B: Silver sulfadiazine is a medication used in the prevention, management, and treatment of burn wound infections. It is a heavy metal topical agent with antibacterial properties. Typically burn dressings consist of topical silver sulfadiazine combined with fine mesh gauze and are usable in both the inpatient and outpatient settings.
Option C: All health facilities practice double-checking of medications prior to administration, Of all the medications given, Amitriptyline is the most important to double-check with another licensed nurse.

NURSESLABS-BURNINJURY-03-003

The nurse is administering fluids intravenously as ordered to a client who acquired a full-thickness burn injury on the abdomen. To determine the sufficiency of fluid resuscitation, the nurse would monitor which of the following would provide the most reliable parameter for determining adequacy?

A. Level of consciousness
B. Peripheral pulses
C. Urine output
D. Vital signs

Correct Answer: C. Urine output

Of all the options, urine output is the most reliable indicator for determining the adequacy of fluid resuscitation. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation.

Option A: Heart rate, mental status, and capillary refill may be affected by the underlying disease process and are less reliable markers. The actual endpoint of fluid therapy in shock is to optimize tissue perfusion. However, this parameter is not measured directly. Surrogate endpoints include clinical indicators of end-organ perfusion and measurements of preload.
Option B: Because of compensatory vasoconstriction, mean arterial pressure (MAP) is only a rough guideline; organ hypoperfusion may be present despite apparently normal values. Because urine output does not provide a minute-to-minute indication, measures of preload may be helpful in guiding fluid resuscitation for critically ill patients.
Option D: Patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Recent literature has raised concerns about complications from over-resuscitation described as “fluid creep.” Again, adequate fluid resuscitation is the goal.

NURSESLABS-BURNINJURY-03-004

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 an 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.

Correct 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. Although a patient may be capable of spontaneous breathing in the early hours after a burn, compromise of the airway can still develop. This may be due to external pressure on the airway, with edema developing in the head and neck region, or in the upper airway due to inhalation of hot gases, including steam or aspiration of hot liquids.

Option A: Split-thickness grafts can cover the extensive defects created after scar release. These grafts will need meticulous attention to achieve complete and early wound closure, but thereafter prolonged splinting will be important to maintain release and prevent contracture.
Option B: In the superficial burn, wound dressings suffice. These can be biological or synthetic. Some medicated elements can prevent secondary infection. Superficial facial wounds can also be treated exposed, with or without the application of topical ointments.
Option D: Opioids may be given to this patient. These burns need to be shaved to preserve residual elements capable of regeneration. Burns of the face and neck rarely fall into aesthetic units, and professional judgment must determine how the excision should be performed. Grafting should be in aesthetic units if at all possible, and sheet grafts should be used on the face.

NURSESLABS-BURNINJURY-03-005

Which of the following routes should the nurse expect the pain medication to be given to a client who was admitted with extensive burns?

A. Oral
B. Intramuscular
C. Subcutaneous
D. Intravenous

Correct Answer: D. Intravenous

For clients with major burns, the intravascular route is the preferred choice of medication administration. Patient-controlled analgesia (PCA) with IV opioids is a safe and efficient method of achieving flexible analgesia in burn-injured patients. Studies comparing PCA with other routes of administration have shown mixed results as to benefit and patient satisfaction.

Option A: Oral NSAIDs and acetaminophen are mild analgesics that exhibit a ceiling effect in their dose-response relationship. Such limitations render these agents unsuitable for the treatment of typical, severe burn pain. Oral NSAIDS and acetaminophen are of benefit in treating minor burns, usually in the outpatient setting.
Option B: In intramuscular drug administration, the absorption of the drug is determined by the bulk of the muscle and its vascularity. The onset and duration of the action of the drug is not adjustable. In case of inadvertent scenarios such as anaphylaxis, burns, or neurovascular injuries, intravenous (IV) assess needs to be secured
Option C: Subcutaneous injections are another form of the parenteral route of medication and are administered to the layer of skin referred to as cutis, just below the dermis and epidermis layers. Subcutaneous tissue has few blood vessels; therefore, the medications injected undergo absorption at a slow, sustained rate.

NURSESLABS-BURNINJURY-03-006

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?

A. Seizure
B. Confusion
C. Flushing
D. Coma

Correct Answer: B. Confusion

Signs and symptoms of carbon monoxide levels between 21-40% (moderate poisoning) include hypotension, tachycardia, headache, drowsiness, confusion, nausea, and vomiting. Mental status changes such as altered level of consciousness, disorientation, and memory loss may occur.

Option A: Carbon monoxide levels of 41% to 60% result in seizures. As carboxyhemoglobin (COHgb) levels rise, the cerebral blood vessels dilate, and both coronary blood flow and capillary density increase. If exposure continues, central respiratory depression develops which may result from cerebral hypoxia.
Option C: Carbon monoxide levels of 11% to 20% result in flushing. The classic symptoms of cherry red nail beds and mucous membranes are not “classic” and are usually post-mortem findings. Patients may also develop ataxia, apraxia, incontinence, and cortical blindness.
Option D: Cardiac effects, especially ventricular arrhythmias occur. Ventricular arrhythmias are implicated as the cause of death most often in CO poisoning. There is evidence that myocardial impairment begins at the relatively low level of COHgb of 20%.

NURSESLABS-BURNINJURY-03-007

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?

A. 36%
B. 54%
C. 45%
D. 27%

Correct Answer: A. 36%

The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients. Based on the rule of nines, the posterior trunk equals 18%, right arm equals 9%, and the left posterior leg equals 9%. Therefore, a total of 36%.

Option B: The Rule of Nines estimation of body surface area burned is based on assigning percentages to different body areas. The entire head is estimated as 9% (4.5% for anterior and posterior). The entire trunk is estimated at 36% and can be further broken down into 18% for anterior components and 18% for the back.
Option C: The anterior aspect of the trunk can further be divided into chest (9%) and abdomen (9%). The upper extremities total 18% and thus 9% for each upper extremity. Each upper extremity can further be divided into anterior (4.5%) and posterior (4.5%).
Option D: The lower extremities are estimated at 36%, 18% for each lower extremity. Again this can be further divided into 9% for the anterior and 9% for the posterior aspect. The groin is estimated at 1%.

NURSESLABS-BURNINJURY-03-008

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.

Correct Answer: B. 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%. Non-rebreathing masks have a bag attached to the mask known as a reservoir bag, which inhalation draws from to fill the mask through a one-way valve and features ports at each side for exhalation, resulting in an ability to provide the patient with 100% oxygen at a higher LPM flow rate.

Options A and C: The nasal cannula is a thin tube, often affixed behind the ears and used to deliver oxygen directly to the nostrils from a source connected with tubing. This is the most common method of delivery for home use and provides flow rates of 2 to 6 liters per minute (LPM) comfortably, allowing the delivery of oxygen while maintaining the patient’s ability to utilize his or her mouth to talk, eat, etc.
Option D: An air-entrainment (also known as venturi) mask can provide a pre-set oxygen to the patient using jet mixing. As the percent of inspired oxygen increases using such a mask, the air-to-oxygen ratio decreases, causing the maximum concentration of oxygen provided by an air-entrainment mask to be around 40%.

NURSESLABS-BURNINJURY-03-009

The nurse is handling a client who sustained an 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?

A. Sensation
B. Color
C. Distal circulation
D. All of the above

Correct 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. A fasciotomy is an emergency procedure used to treat acute compartment syndrome. Acute compartment syndrome often follows high energy trauma, fractures, circumferential burns, crush injuries, or even a tight plaster cast.

Option A: Loss of sensation can signal compartment syndrome. Classical features of compartment syndrome are those of ischemia, pain out of proportion to the injury, paraesthesia, pallor, paralysis, and pain on passive movement, especially stretch of the concerned compartment.
Option B: Pallor is associated with compartment syndrome. Fasciotomy wound management begins with an inspection at 48 hours. If the compartments are soft, this closure is achievable by primary wound closure, secondary wound healing, or as needed in approximately 50% of wounds split-thickness skin grafting.
Option C: Distal circulation should be checked to prevent ischemia. Two-point discrimination can be useful for determining nerve ischemia. These signs and symptoms can be challenging to assess depending on the conscious level, sensory state, and ability to communicate.

NURSESLABS-BURNINJURY-03-010

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 activities 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.

Correct 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. Clinically, skin grafts are secured into place and often bolstered until postoperative day 5 to 7 to allow the skin graft to go through the above steps, ensuring the best skin graft take.

Option B: Do not place the affected leg in a dependent position. Any buildup of fluid between the split-thickness skin graft and wound bed will jeopardize skin graft take, including seroma, hematoma, and infection. Shear or traction injury also disrupts skin graft healing.
Option C: Dangling of legs puts the affected site into a dependent position, which can cause a build-up of fluid that jeopardizes the skin graft. The graft can have incomplete (less than 100%) take or complete nontake.
Option D: Split-thickness skin grafts typically become adherent to the recipient wound bed 5 to 7 days following skin graft placement. The dressings placed intraoperatively are kept in place until 5 to 7 days postoperatively to minimize shear and traction to the healing skin graft.

NURSESLABS-BURNINJURY-03-011

Nurse Troyzan has just received the change-of-shift report in the burn unit. Which of the following clients 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 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 and has been crying since recent visitors left.

Correct Answer: B. A 40-year-old with partial-thickness leg burns which has a temperature of 101.9°F and blood pressure of 89/48 mm Hg.

The client’s vital signs indicate that life-threatening complications of sepsis may be developing. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury. If the patient’s host defenses and therapeutic measures (including excision of necrotic tissue and wound closure) are inadequate or delayed, microbial invasion of viable tissue occurs, which is the hallmark of an invasive burn wound infection.

Option A: Classically, hyperkalemia has been regarded as a complication in patients with electrical burns. The etiology of hyperkalemia includes metabolic acidosis, destruction of red blood cells, rhabdomyolysis, and the development of renal failure.
Option C: Oral NSAIDs and acetaminophen are of benefit in treating minor burns, usually in the outpatient setting. For hospitalized burn patients, opioids are the cornerstone of pharmacologic pain control. Patient-controlled analgesia (PCA) with IV opioids is a safe and efficient method of achieving flexible analgesia in burn-injured patients.
Option D: Symptoms of depression and anxiety are common and start to appear in the acute phase of recovery. Acute stress disorder (occurs in the first month) and post-traumatic stress disorder (occurs after one month) are more common after burns than other forms of injury.

NURSESLABS-BURNINJURY-03-012

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

Correct 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. The acute phase of burns is defined as a period extending from the onset of burns with shock to the time taken for wound epithelialization which normally takes about 12 to 14 days if the management of burns is adequate. The first 48 is the period of shock.
Option C: Pulse rate is higher than normal. If resuscitation is carried out urgently the circulatory shock is not only prevented, none of the complications of shock are allowed to manifest.
Option D: Initially, blood is shunted away from the kidneys, resulting in low urine output. The greatest amount of fluid loss in burn patients is in the first 24 h after injury. For the first 8-12 hours, there is a general shift of fluids from intravascular to interstitial fluid compartments. This means that any fluid given during this time will rapidly leak out from the intravascular compartment.

NURSESLABS-BURNINJURY-03-013

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.

Correct Answer: D. Wearing gloves and a gown only when giving direct care to the client.

Thorough hand washing is performed before and after each contact with the burn-injured client. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.

Option A: The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.
Option B: Protective garbs such as masks, gloves, caps, shoe covers, gowns, and a plastic apron need to be worn when having direct contact with the client. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination.
Option C: Sterile sheets and linen are used due to the high risk of infection. Soiled textiles, including bedding, towels, and patient or resident clothing may be contaminated with pathogenic microorganisms. However, the risk of disease transmission is negligible if they are handled, transported, and laundered in a safe manner.

NURSESLABS-BURNINJURY-03-014

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.

Correct 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 increased amount of lactated Ringer’s solution administered hourly. Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.” Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation.

Option B: Blood transfusion is not used for fluid resuscitation therapy unless there is an indication of a low hemoglobin level. This response, along with decreased cardiac output and increased vascular resistance, can lead to marked hypovolemia and hypoperfusion called “burn shock.” This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids.
Option C: Diuretic works by removing circulating volume, thereby further compromising the inadequate tissue perfusion. The patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Again, adequate fluid resuscitation is the goal.
Option D: Dextrose in water will only maintain fluid balance since it is an isotonic solution, therefore will not be helpful in this situation. Four mL lactated ringers solution × percentage total body surface area (%TBSA) burned × patient’s weight in kilograms = total amount of fluid given in the first 24 hours.

NURSESLABS-BURNINJURY-03-015

Nurse Kelsey is a nurse manager assigned to the burn unit. Which client is best to assign 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.

Correct 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. There are several options for burn dressings. Some are impregnated with antimicrobials (eg, silver). Most are a form of gauze, but there are biosynthetic dressings with some of the characteristics of skin that adhere to the wound and can be left in place for extended periods of time.

Option B: Admission assessment requires expertise in caring for burn patients. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care.
Option C: Splinting requires expertise in caring for burn patients. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
Option D: Discharge teaching requires expertise in caring for burn patients. Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so.

NURSESLABS-BURNINJURY-03-016

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

Correct 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 heals within a week, without scarring. Superficial burns (first degree) involve only the epidermis and are warm, painful, red, soft, and blanch when touched. Usually, there is no blistering. A typical example is a sunburn.
Option B: Pale pink or mottled appearance with associated swelling and small blisters. 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. Full-thickness burns (third degree) extend through both the epidermis and dermis and into the subcutaneous fat or deeper. These burns have little or no pain, can be white, brown, or charred, and feel firm and leathery to palpation with no blanching.

NURSESLABS-BURNINJURY-03-017

Which of the following refers to a wound covering brought about by the donated human cadaver skin provided by the skin bank?

A. Autograft
B. Homograft
C. Heterograft
D. Xenograft

Correct Answer: B. Homograft

Homograft is a tissue graft from a donor of the same species as the recipient. Skin from organ donors can be used as a temporary covering. It is temporary because this skin will eventually be rejected. This is known as a homograft. Homografts may be required initially if the injured area is too large to be covered by the patient’s own skin.

Option A: A skin graft, also known as an autograft, involves taking skin from an unburned part of the patient’s body and placing it on the wound after the burn has been removed.
Option C: Pigskin grafts are termed xenografts, or heterografts because they are transplanted from an organism of one species to that of a different species. Both allografts and xenografts are biologic dressings only, are ultimately rejected by the patient’s immune system, and need to be removed prior to definitive wound treatment or skin grafting.
Option D: Xenograft is a graft of tissue taken from a donor of one species and grafted into a recipient of another species. While xenografts are rejected before undergoing revascularization, allografts initially undergo revascularization but are typically rejected after approximately 10 days because of the strong antigenicity of the skin.

NURSESLABS-BURNINJURY-03-018

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.

Correct Answer: B. Avoid smoking.

Smoking can decrease the blood supply to the newly graft recipient bed interface, and the chance of graft failure increases. The combined effect of nicotine and carbon monoxide is deadly to the healing process. This can result in partial or complete loss of healing of the wound, skin graft, flap, or any combination of these. This can compromise the cosmetic results of the surgery.

Option A: Static or primary splints are used in the acute phase for skin graft protection after surgery or anti contracture positioning. These splints are applied to adjacent intact skin.
Option C: Healed burns or skin grafts may be extremely sensitive to sunlight and may sunburn more severely even after short periods of time in the sun compared to before the injury. Sun sensitivity after a burn injury may last for a year or more.
Option D: At least 3 weeks after surgery, avoid exercise that stretches the skin graft, unless the doctor gives other instructions. If the graft was placed on the legs, arms, hands, or feet, the patient may need physiotherapy to prevent scar tissue from limiting movement.

NURSESLABS-BURNINJURY-03-019

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.”

Correct Answer: C. “It is performed at the bedside and without anesthesia”.

An escharotomy is performed at the bedside and without anesthesia since nerve endings have been destroyed by the burn injury. An escharotomy is an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation.

Option A: A skin graft, also known as an autograft, involves taking skin from an unburned part of the patient’s body and placing it on the wound after the burn has been removed.
Option B: Escharotomy involves making a lengthwise incision through the burn eschar to relieve vasoconstriction. The incisions should extend from unburnt skin to unburnt skin ideally, or at least into areas of more superficial burns, down to subcutaneous fat, and release any constrictions.
Option D: This is a selective method for debridement of necrotic tissue using an exogenous proteolytic enzyme, collagenase, to debride Clostridium bacteria. Collagenase digests the collagen in the necrotic tissue allowing it to detach.

NURSESLABS-BURNINJURY-03-020

Rehabilitation is the final phase of 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.

Correct Answer: A, C, and E.

The rehabilitation phase starts after wound closure and ends upon discharge and beyond. The goals of this phase include minimizing functional loss, promoting psychosocial support, promoting wound healing, and proper nutrition.

Option A: Patients may try to refuse treatment as they are in pain and may not fully understand the impact of not participating in their rehabilitation; they, therefore, need the support and encouragement of the burn care professionals to help them through this difficult experience with the knowledge of how different their quality of life can be.
Option B: Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours peaking at around six to eight hours after injury. This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids.
Option C: Continuous monitoring and reassessment of nutritional status with modifications in nutritional therapy as indicated can accommodate the unique yet diverse needs of this population and support their therapeutic goals for recovery.
Option D: Belong to the main goal during the resuscitative phase. Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.”
Option E: A comprehensive rehabilitation program is essential to decrease a patient’s post-traumatic effects and improve functional independence. While different professionals possess expertise in their own specialties, there are some simple and effective methods that can be utilized to help the patient reach their maximum functional outcome.

Burns NCLEX Question and Burn Injury Nursing Management Quiz #4 (20 Items)

NURSESLABS-BURNINJURY-04-001

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

Correct Answer: D. Full thickness

The characteristics of the wound 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). With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

Option A: Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.
Option B: Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.
Option C: Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.

NURSESLABS-BURNINJURY-04-002

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

Correct Answer: B. Partial-thickness superficial

The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high). Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.

Option A: Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.
Option C: Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.
Option D: Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

NURSESLABS-BURNINJURY-04-003

The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

A. The medication will be effective more quickly than if given intramuscularly.
B. It is less likely to interfere with the client’s breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.

Correct Answer: C. The danger of an overdose during fluid remobilization is reduced.

The most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

Option A: Providing some pain relief has a high priority and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect. Pain that is more severe and not well controlled may be manageable with single or continuous doses of IV, epidural, and intrathecal formulations. Infusion dosing can vary significantly between patients and largely depends on how naive or tolerant they are to opiates.
Option B: Respiratory depression is among the more serious adverse reactions with opiate use that is especially important to monitor in the postoperative patient population. Extreme caution is necessary with severe respiratory depression and asthma exacerbation cases since morphine can further decrease the respiratory drive.
Option D: Delayed gastric emptying is not a side effect of morphine. Among the more common unwanted effects of morphine use is constipation. This effect occurs via stimulation of mu-opioid receptors on the myenteric plexus, which in turn inhibits gastric emptying and reduces peristalsis.

NURSESLABS-BURNINJURY-04-004

Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

Correct Answer: D. Vitamin D

Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full-thickness burns. The loss of healthy skin following a burn injury can decrease epidermal vitamin D production. Additionally, low vitamin D levels have been reported to have continued for 7 years post-burn in pediatric outpatients.

Option A: Vitamin A deficiency (VAD) is a highly prevalent health concern associated with substantial morbidity and mortality, mostly affecting young children in impoverished regions throughout the world. Insufficient intake of absorption leads to deficiency and compromise of essential physiologic processes.
Option B: Vitamin B12 deficiency can lead to hematologic and neurological symptoms. Vitamin B12 is stored in excess in the liver, decreasing the likelihood of deficiency. However, in cases in which vitamin B12 cannot be absorbed, for example, due to dietary insufficiency, malabsorption, or lack of intrinsic factor, hepatic stores are depleted, and deficiency ensues.
Option C: Vitamin C deficiency, also known as scurvy, is a disease primarily associated with socioeconomic status and access to food. Signs and symptoms are often readily visible in individuals who develop this disease. The classic constellation of corkscrew hairs, perifollicular hemorrhage, and gingival bleeding is highly suggestive of vitamin C deficiency.

NURSESLABS-BURNINJURY-04-005

Which client factors should alert the nurse to potential increased complications with a burn injury?

A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.

Correct Answer: C. The burned areas include the hands and perineum.

Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome. Complications are related to the extension of the burn. Burns to the genitalia and perineum are severe conditions that all urologists should be familiar with and know how to manage. Fluid resuscitation is the initial step in treating these patients and is followed by topical dressings in the case of superficial burns.

Option A: Irrespective of the type of burn injury, the aged population shows slower recoveries and suffers more complications. Age-associated immune dysfunction, immunosenescence, may predispose the elderly burn patients to more infections, slower healing, and/or to other complications.
Option B: Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life.
Option D: Burns to the genitals correspond to approximately 2% of all burn patients in North American case series. The majority of those cases are associated with greater burned body surface areas, in which direct fire and scalding are the most frequent causes. Burn management begins with opportune diagnosis and entails making the correct classification, depending on the depth of the lesion.

NURSESLABS-BURNINJURY-04-006

The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?

A. “To increase urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”

Correct Answer: C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”

Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.

Option A: Adequate fluid therapy is crucial in maintaining renal function. Monitoring by urine output or Swan-Ganz catheterization and thermodilution cardiac output determination is useful in the circulatory management of severely burned patients. Albumin infusion increases plasma volume by 37% and normalizes elevated basal levels of aldosterone and plasma renin activity.
Option B: Other management for severe burns includes nasogastric tube placement as most patients will develop ileus. Foley catheters should be placed to monitor urine output. Cardiac and pulse oximetry monitoring are indicated. Pain control is best managed with IV medication.
Option D: Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.” A variety of formulas exist, like Brooke, Galveston, Rule of Ten, etc.4, but the most common formula is the Parkland Formula. This formula estimates the amount of fluid given in the first 24 hours, starting from the time of the burn.

NURSESLABS-BURNINJURY-04-007

At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?

A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase

Correct Answer: C. During fluid remobilization

Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output. In an attempt to prevent hypokalemia it is advised to add ’20-30 mEq/1 of potassium to the hypotonic fluids in order to compensate for urinary losses and intracellular shift; it is also mandatory to correct precipitating factors such as increased pH, hypomagnesemia, and several drugs.

Option A: In major burns. intravascular volume is lost in burned and unburned tissues: this process is due to an increase in vascular permeability, increased interstitial osmotic pressure in burn tissue. and cellular edema. with the most significant shifts occurring in the first hours. Hyponatremia is frequent, and the restoration of sodium losses in the burn tissue is, therefore, essential hyperkalemia is also characteristic of this period because of the massive tissue necrosis.
Option B: The early post-resuscitation phase is a period of transition from the shock phase to the hypermetabolic phase, and fluid strategies should change radically with a view to restoring losses due to water evaporation. The main changes in this period are hypernatremia, hypocalcemia, hypokalemia, hypomagnesemia, and hypophosphatemia.
Option D: The acute phase of burns is defined as a period extending from the onset of burns with shock to the time taken for wound epithelialization which normally takes about 12 to 14 days if management of burns is adequate.

NURSESLABS-BURNINJURY-04-008

What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum

Correct Answer: C. Cherry red color to the mucous membranes

The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a “cherry red” color of the mucous membranes in these clients. Cherry-red skin color associated with severe carbon monoxide poisoning is seen in only 2-3% of symptomatic cases. Skin may develop erythematous lesions and bulla, especially over bony prominences.

Option A: Carbon monoxide quickly binds with hemoglobin with an affinity greater than that of oxygen to form COHb. The resulting decrease in arterial oxygen content and shift of the oxyhemoglobin dissociation curve to the left explains the acute hypoxic symptoms (primarily neurologic and cardiac) seen in patients with acute poisoning.
Option B: Patients suffering from smoke inhalation may have symptoms of burning sensation in the nose or throat (which is often caused by an irritant chemical toxin), a cough with increased sputum production, stridor, and dyspnea with rhonchi or wheezing.
Option D: The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning. Physical examination should include looking for facial burns, such as loss of facial and intranasal hair as well as carbonaceous material or soot in the mouth or sputum.

NURSESLABS-BURNINJURY-04-009

What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the extremity.

Correct Answer: C. Capillary refill is slow in the digits and the distal pulse is absent.

Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure, and preventing blood flow to the distal extremities, and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy.

Option A: The American Burn Association recommends burn center referrals for patients with full-thickness burns. Patients being transferred to burn centers do not need extensive debridement or topical antibiotics before transfer.
Option B: Once established, burn contractures can be treated with serial splinting, release of contracting bands with Z-plasties, incision, and skin grafting or excision, and resurfacing with skin grafts or flaps, local rotation flaps, use of tissue expanders, or with free flap reconstruction.
Option D: After a deep burn injury, cutaneous nerve regeneration will occur with the migration of new nerve fibers from the wound bed or from the collateral sprouting of nerve fibers from adjacent uninjured areas. This nerve regeneration process is imperfect. It was reported that 71% of extensively burned victims suffer from abnormal sensations and 36% from chronic pain. Recent studies on rats have shown that vagus nerve stimulation improved thermal injury-induced shock symptoms.

NURSESLABS-BURNINJURY-04-010

What additional laboratory test should be performed on any African American client who sustains a serious burn injury?

A. Total protein
B. Tissue type antigens
C. Prostate-specific antigen
D. Hemoglobin S electrophoresis

Correct Answer: D. Hemoglobin S electrophoresis

Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client’s sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury.

Option A: Burn patients can also have important reduction in albumin level due to a higher vascular permeability in the burn wounds that produces exudation with an important protein loss through the burn wound and acute phase response of plasma protein synthesis in liver that occurs with even a very small percentage of burn skin (0.8%) and that produces a decrease to about 80% of normal albumin and prealbumin levels.
Option B: Immunochemical studies of the sera of patients with severe burns led to the conclusion that as soon as within the first two days following the trauma, tissue antigens sharing common components with those of the burned and normal skin were detected in the blood. The antigens in question were not detected in the sera of healthy subjects and were not identical with the C-reactive protein. Long-term circulation of these antigens, i.e. for 2 to 3 months after burning, was revealed.
Option C: For the detection of prostate cancer, an elevated serum prostate-specific antigen is the most common laboratory abnormality, as the majority of men with early prostate cancer have no symptoms. However, prostate-specific antigen, otherwise known as PSA, is clinically imprecise as benign and malignant processes both can elevate the serum marker.

NURSESLABS-BURNINJURY-04-011

Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells

Correct Answer: B. Crystalloids

Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer’s lactate. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted.

Option A: Colloids are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult.
Option C: Fresh frozen plasma appears to be a useful and effective immediate burn resuscitation fluid but its benefits must be weighed against its costs, and risks of viral transmission and acute lung injury.
Option D: The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involves hemorrhage. Ongoing blood loss, anemia, hypoxia, and cardiac disease are the most common reasons for blood transfusion in burn patients. Other important causes include age, percentage of burn (TBSA), need for further operation, presence of acute respiratory distress syndrome, sepsis, and evidence of cardiac ischemia.

NURSESLABS-BURNINJURY-04-012

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

Correct Answer: B. Loosen the dressing.

Option A: It is unnecessary to administer oxygen. Wearing pressure garments is uncomfortable and challenging; problems with movement, appearance, fit, comfort, swelling of extremities, rashes, and blistering are common; consequently, low compliance with PGT is to be expected.
Option C: The nurse may intervene first. However, monitoring of pressure exerted by pressure garments is currently difficult and time-consuming, and not routinely done and currently, the optimal pressure magnitude for PGT remains unsolved.
Option D: The nurse may loosen the dressing to help the client breathe. Recent evidence suggests that pressure garment therapy is effective for the prevention and/or treatment of abnormal scarring after burn injury but that the clinical benefit is restricted to those patients with moderate or severe scarring.

NURSESLABS-BURNINJURY-04-013

The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?

A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.

Correct Answer: B. Notify the emergency team.

Option A: Raising the head of the bed would be not much help because of the obstructed airway. Airway protection should include considering early and preemptive intubation for patients with inhalation injury.
Option C: Dressings may be loosened, but emergency intubation would still be needed. Airway edema may occur suddenly as edema worsens, and often, the upper airways develop injury and obstruction earliest, prior to the parenchymal injury.
Option D: This is not a normal finding. There may be accessory muscle usage, tachypnea, cyanosis, stridor, and rhonchi/rales/wheezing. Findings of stridor or upper airway turbulence/noise are often a sign of impending airway compromise, and prompt intubation should be strongly considered.

NURSESLABS-BURNINJURY-04-014

Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?

A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

Correct Answer: B. Document the finding as the only action.

Option A: The glucose level is not high enough to alert the emergency team. A variety of laboratory tests will be needed within the first 24 hours of a patient’s admission (some during the initial resuscitative period and others after the patient is stabilized).
Option C: 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 secondary assessment shouldn’t begin until the primary assessment is complete; resuscitative efforts are underway; and lines, tubes, and catheters are placed.
Option D: Infusion of an IV fluid containing dextrose may further increase the client’s blood glucose. The ideal burn resuscitation is the one that effectively restores plasma volume, with no adverse effects. Isotonic crystalloids, hypertonic solutions, and colloids have been used for this purpose, but every solution has its advantages and disadvantages. None of them is ideal, and none is superior to any of the others.

NURSESLABS-BURNINJURY-04-015

On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response?

A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning

Correct Answer: A. Fluid shift

The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure. After a burn, fluid shifts from vascular to interstitial and intracellular spaces because of increased capillary pressure, increased capillary and venular permeability, decreased interstitial hydrostatic pressure, chemical inflammatory mediators, and increased interstitial protein retention.

Option B: Intense pain and carbon monoxide poisoning increase blood pressure. Superficial dermal burns are initially the most painful. Even the slightest change in the air currents moving past the exposed superficial dermis causes a patient to experience excruciating pain. Without the protective covering of the epidermis, nerve endings are sensitized and exposed to stimulation.
Option C: Hemorrhage is unusual in a burn injury. The difference with a burn is the heat actually stops the blood from flowing. A small bit of blood may ooze out at first, but it won’t actually bleed much.
Option D: Most commonly, patients with carbon monoxide poisoning will present with headache (more than 90%), dizziness, weakness, and nausea. Patients may be tachycardic and tachypneic. They may exhibit hypotension. Mental status changes such as confusion, altered level of consciousness, disorientation, and memory loss may occur.

NURSESLABS-BURNINJURY-04-016

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?

A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.

Correct Answer: B. Document the finding as the only action.

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. After the mid and late 1990s, the idea of staged food intake was advanced: a small amount of light fluid is started several hours after burn so as to not only supplement nutrition but stimulate GI peristalsis and improve GI blood supply. Once bowel sound resumes, the amount of food can be increased.

Option A: Post-burn GI dysfunction is caused by multiple factors, and therefore maintaining GI function is a systematic engineering project. The therapeutic strategy should not rely on a single treatment or a single drug.
Option C: It is suggested that small doses of dopamine should be administered to dilate the renal and GI vessels, and free oxygen radical clearing agents to attenuate ischemia/reperfusion injury in the process of resuscitation. These comprehensive resuscitation measures played an important role in protecting GI function, helping resume bowel sound earlier and digestive function.
Option D: In some patients in whom fluid resuscitation was not implemented effectively for various reasons, wound surface infection often caused severe injury to the GI function, or even toxic paralytic ileus palsy, greatly increasing toxin absorption and bacterial superinfection.

NURSESLABS-BURNINJURY-04-017

Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

A. Increased urine output, decreased urine specific gravity
B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit

Correct Answer: A. Increased urine output, decreased urine specific gravity

The “fluid remobilization” phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity. Injured capillaries heal approximately 24 to 36 hours after a burn, so intravascular fluid loss typically ceases at this time, and fluid begins to shift back into the intravascular compartment. This stage is called the fluid remobilization period.

Option B: Edema develops when the rate at which fluid is filtered out of the capillaries exceeds the flow in the lymph vessels. Edema formation often follows a biphasic pattern. An immediate and rapid increase in the water content of burned tissue is seen in the first hour after burn injury.
Option C: Inadequate fluid resuscitation is the most common cause of diminished distal pulses in the newly burned patient. Another potential cause of diminished pulses is peripheral edema, which develops in many severe burn patients due to the large fluid volumes needed for resuscitation.
Option D: Hyponatraemia is frequent, and the restoration of sodium losses in the burn tissue is, therefore, essential hyperkalemia is also characteristic of this period because of the massive tissue necrosis. Following a severe burn injury, significant hematologic changes occur that are reflected in complete blood count (CBC) measurements. Over the first week after injury, HGB and HCT decreased. This decrease was due to loss of red blood cells. WBC counts were initially elevated but decreased over the first 4 days. PLT also decreased over the first 4 days.

NURSESLABS-BURNINJURY-04-018

What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?

A. Risk for Ineffective Breathing Pattern
B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image

Correct Answer: C. Risk for Disuse Syndrome

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury.

Option A: Chemical burns do not cause inhalation injury and a disrupted breathing pattern. The most common findings represent structural changes to the tissue directly affected, for example, the eye, oral mucosa, skin, esophagus, and lower intestinal system, especially the stomach and pylorus, respiratory system, among others.
Option B: During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy.
Option D: Disturbed body image can develop. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.

NURSESLABS-BURNINJURY-04-019

All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

A. Serum sodium elevated to 131 mmol/L (mEq/L)
B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%

Correct Answer: B. Serum potassium 7.5 mmol/L (mEq/L)

All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk of experiencing severe cardiac dysrhythmias and death.

Option A: Serum sodium is abnormal, but not to the same degree of severity, and would be expected in the emergent phase after a burn injury. Severe cutaneous injuries such as burn injuries and blast injuries result in the loss of both water and sodium. For burn patients, hypernatremia that occurs within a few days of injury may be associated with increased risk of death.
Option C: Acid-base studies were carried out on 76 consecutive burn patients admitted within 36 hours of injury. Admission blood pH and base excess (BE) values all decreased in a linear relationship to the extent of the burn. Blood Pco-2 changes were unrelated to the extent of the burn. Significant acidosis developed within 2 hours of burn injury.
Option D: The hematocrit (Hct) is the percentage of the volume of the whole blood that is made up of red blood cells. In burns, the patient has lost a lot of fluid from leaky blood vessels. There are more red cells than fluid so the hematocrit is high.

NURSESLABS-BURNINJURY-04-020

The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What is the priority assessment data to obtain from this client on admission?

A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities

Correct Answer: B. Heart rate and rhythm

Option A: The airway is not at any particular risk with this injury. Any patient that was in contact with a high voltage source should have continuous cardiac monitoring during evaluation.
Option C: These patients are specifically at risk for cardiac damage if the path of the current traversed the heart. One may also consider CT imaging of the head if the patient has altered mental status or associated head trauma from a fall or being thrown in a blast.
Option D: Range of motion is also 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.

Burns NCLEX Question and Burn Injury Nursing Management Quiz #5 (20 Items)

NURSESLABS-BURNINJURY-05-001

In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

A. “Are you a smoker?”
B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”

Correct Answer: D. “In what exact place or space were you when you were burned?”

The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. The composition of smoke varies with each fire depending upon the materials being burned, the amount of oxygen available to the fire, and the nature of the fire. It is important to elucidate whether the exposure was to smoke, flames, and/or possible chemicals (both industrial and household). Duration of exposure, the location of exposure (such as if it was in an enclosed space), and any loss of consciousness are all important as well.

Option A: Although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury. History-taking should be complete and thorough. Burn patients may have extensive external injuries, but smoke inhalation may affect those with no outward signs of burns.
Option B: Workup of smoke inhalation injury may include serial chest radiographs (often negative early in smoke inhalation injury) and computed tomography (CT) chest. A delay in the onset of symptoms is not uncommon, and clinicians should educate patients on the possibility of delayed symptom onset post-exposure. The delayed symptoms occur in the lower respiratory airways as it is caused by chemical toxin exposure, which may bypass the upper airways.
Option C: Short-term complications are seen in more severe injuries within 4 to 5 days, and the most common issue is pneumonia. Acute respiratory distress syndrome and pulmonary edema are also seen in the short term.

NURSESLABS-BURNINJURY-05-002

Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited.

Correct Answer: C. The client’s oxygen saturation is 97%.

Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

Option A: A thorough respiratory assessment consists of inspection, palpation, percussion, and auscultation in conjunction with a comprehensive health history. Use a systematic approach and compare findings between left and right so the patient serves as his own control.
Option B: Respirations should be even, unlabored, and regular at a rate of 12 to 20 breaths per minute. Normally, inspiration is half as long as expiration, and chest expansion is symmetrical. If the client appears anxious or exhibits nasal flaring, cyanosis of the lips and mouth, intercostal retraction, or use of accessory muscles of respiration, he may be in respiratory distress.
Option D: Normally, the thorax is symmetrical and the anterior-posterior diameter is less than the transverse diameter. (Equal diameters may signal chronic obstructive pulmonary disease in an adult.) Note any structural deformity such as a pigeon chest (pectus carinatum) or funnel chest (pectus excavatum).

NURSESLABS-BURNINJURY-05-003

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?

A. Emergent Phase
B. Immediate Resuscitative Phase
C. Acute Phase
D. Rehabilitation Phase

Correct Answer: C. Acute Phase

The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care that includes wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting, pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.

Option A: The emergent phase begins with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of client care involves maintaining an adequate airway and treating the client for burn shock.
Option B: Priorities during the immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care.
Option D: The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

NURSESLABS-BURNINJURY-05-004

The burned client’s family asks at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

A. “When fluid remobilization has started.”
B. “When the burn wounds are closed.”
C. “When IV fluids are discontinued.”
D. “When body weight is normal.”

Correct Answer: B. “When the burn wounds are closed.”

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 great risk for infection as long as any area of skin is open.

Option A: Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.
Option C: The important point to remember is the fluid amount calculated is just a guideline. Patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation. Recent literature has raised concerns about complications from over-resuscitation described as “fluid creep.” Again, adequate fluid resuscitation is the goal.
Option D: Severe burn is associated with significant changes in body weight due to large resuscitation volumes, fluid shifts, a hypermetabolic state, prolonged bed rest, and caloric intake. Weight gain in the severely burned patient often follows initial fluid resuscitation, which can increase weight by up to 10–20 kg.

NURSESLABS-BURNINJURY-05-005

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month

Correct Answer: C. Myocardial infarction 1 year ago

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation. The initial response to severe burn injury or early shock state is characterized by a decrease in cardiac output and metabolic rate. The reduction in cardiac output is partially due to hypovolemia and reduced venous return.

Option A: Systemic effects may occur especially after inhalation injury. Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of pro-inflammatory cytokines, as well as direct effects from metabolic poisons such as carbon monoxide and cyanide.
Option B: A history of hepatitis B does not affect the fluid resuscitation plan. Fluid creep in patients recovering from acute burns still exists, despite the use of a more treatment conservative approach. Most severe burn patients develop fluid overload and body weight increase after acute fluid resuscitation. How to quickly return patients to their pre-injury body weight is an important issue
Option D: Acute renal failure is one of the major complications of burns and it is accompanied by a high mortality rate. Most renal failures occur either immediately after the injury or at a later period when sepsis develops.

NURSESLABS-BURNINJURY-05-006

The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?

A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.

Correct Answer: C. Auscultate breath sounds over the trachea and mainstem bronchi.

Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly. Close physical examination of patients with inhalation injury can reveal signs of smoke inhalation, including facial burns, perioral burns, and singed nasal hairs. This warrants laryngoscopy and evidence of significant edema, blisters, or ulcerations should lead to consideration for intubation to stabilize the airway.

Option A: Neurovascular assessment may be done after establishing a patent airway. Inhalation of smoke also leads to the absorption of many toxins in the blood, including carbon monoxide and cyanide, thereby causing the entire body to be affected, and making inhalational injury a systemic insult.
Option B: History taking can be done after the patient has been deemed stable. It is well known that rapid diagnosis and treatment are key when it comes to inhalational burns, as acute complications, which sometimes go unnoticed, are the reason behind long-term sequels and the high mortality rate seen with this type of injury.
Option D: GI assessment is not a priority. Edema of the oral mucosa and/or the trachea can develop within 0.5 hours of the time of injury and can progress to mucosal necrosis within 12-24 hours. Supraglottic injury, swelling, and resulting obstruction of the airway occur more commonly in children due to the smaller size of the trachea, and relatively large epiglottis.

NURSESLABS-BURNINJURY-05-007

Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

A. Handwashing on entering the client’s room
B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas

Correct Answer: A. Handwashing on entering the client’s room

Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations. Emphasize and model good handwashing techniques for all individuals coming in contact with the patient.

Option B: Although all the interventions listed above can help reduce the risk of infection, only handwashing can prevent cross-contamination. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn.
Option C: Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
Option D: Serious complications often can be avoided by following strict aseptic techniques. Use of a mask, hat, gown, and sterile gloves, and drapes during placement of central venous catheters (CVCs) should be strictly implemented.

NURSESLABS-BURNINJURY-05-008

In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?

A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 1,800/mm3.

Correct Answer: C. The “bands” outnumber the “segs.”

Normally, the mature segmented neutrophils (“segs”) are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature “band” neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client’s immune system cannot keep pace with the infectious process.

Option A: The normal WBC count is 4,500 to 11,000/mm3. Burn injury causes systemic inflammatory response. The magnitude of the changes is roughly a function of burn size that is manifested by increased body temperature, increased WBC count, and increased metabolic rate, which makes diagnosis of infection in the burned patient more difficult.
Option B: Peripheral blood lymphocytes represent the most important line of host defense against pathogenic microorganisms in humans. Researchers found a reduction in the number of lymphocytes as well as WBC, which may contribute to the impairment of general mechanisms for immune regulation during burn shock and transition of blood to the level of self-regulation.
Option D: The normal monocyte count ranges from 100-700 per mm³ (2–8%). Severe burn and sepsis profoundly inhibit the functions of DC, monocyte, and macrophage. These phagocytes are the first cellular responders to severe burn injury after acute disruption of the skin barrier.

NURSESLABS-BURNINJURY-05-009

The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?

A. Place a towel roll under the client’s neck or shoulder.
B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour while awake.
D. Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.

Correct Answer: C. Have the client turn the head from side to side 90 degrees every hour while awake.

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. Deformities and contractures can often be prevented by proper positioning. Maintaining proper body alignment when the patient is in bed is vital. This movement is what would prevent contractures from occurring.

Option A: Placing a towel roll under the neck might not help prevent contractures. Immobilization is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an antideformity position.
Option B: The client should not only be in a supine position but there should be a movement to avoid contractures. Splinting and proper positioning will also help achieve the prevention of contractures. As a matter of importance, movement should be incorporated into the patient’s daily routine from their inception to the hospital.
Option D: The burns are in the client’s posterior neck. Performing active or passive range of motion (ROM) exercises, depending on the patient’s level of consciousness is crucial in the prevention of these complications.

NURSESLABS-BURNINJURY-05-010

The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintains to retain maximum function of this joint?

A. Hip maintained in 30-degree flexion, no knee flexion
B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat

Correct Answer: D. Hip at zero flexion with leg flat

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 at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion.

Option A: Anti-contracture positioning and splinting must start from day one and may continue for many months post-injury. Legs should be positioned in a neutral position ensuring that the patient is not externally rotating at the hips.
Option B: When burns occur to the flexor aspect of a joint or limb the risk of contracture is greater. This is due to the position of comfort being a flexed position; also the flexor muscles are generally stronger than the extensors so should a burn occur to the extensor aspect, patients can use the strength of the flexors to stretch the particular area.
Option C: Patients rest in a position of comfort; this is generally a position of flexion and also the position of contracture. Without ongoing advice and help with positioning, the patient will continue to take the position of contracture and can quickly lose ROM in multiple joints. Once contracture starts to develop it can be a constant battle to achieve full movement, so preventative measures to minimize contracture development are necessary.

NURSESLABS-BURNINJURY-05-011

A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level

Correct Answer: D. Increased serum creatinine level

Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. 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.

Option A: Gentamicin does not stimulate pain in the wound. The gentamicin is prone to accumulate in the renal proximal tubular cells and can cause damage. Hence, mild proteinuria and reduction of the glomerular filtration rate are potential consequences of gentamicin use, achieving 14% of gentamicin users in a review.
Option B: The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Renal function should be evaluated twice-weekly in patients without previous renal disease through serum creatinine and blood urea nitrogen. Periodic microscopic urinalysis is also vital to detect proteinuria and casts, which may indicate kidney injury.
Option C: The possible hypersensitivity manifestations of gentamicin are urticaria, eosinophilia, delayed-type hypersensitivity reaction (Stevens-Johnson syndrome and toxic epidermal necrolysis), angioedema, and anaphylactic shock. The clinical manifestations should guide the treatment strategy.

NURSESLABS-BURNINJURY-05-012

The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?

A. Nothing, because the findings are normal for clients during the acute phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.

Correct Answer: D. Notify the burn emergency team.

These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention. Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues.

Option A: Invasive infection is now the chief reason for death and morbidity after burn injury, with it being responsible for 51% of the deaths. The importance of prevention, surveillance, and sampling for infections in this immunocompromised group has been well established; however, there is a dearth of standard-of-care guidelines and novel approaches.
Option B: Urgent resuscitation measures are required, along with broad-spectrum antimicrobial agents, antifungals, and surgical debridement of the affected area. Specimens of this tissue must undergo histopathologic and microbiologic analysis to assist in the identification of the causative organism(s).
Option C: Assessment of the airway and oxygen saturation would not help in diagnosing a burn infection. Burn wound colonization may be diagnosed when bacteria are present at low concentrations (<105 colony-forming units [CFU]) on the wound’s surface. This situation often is accompanied by signs of sepsis and changes in the burn wound such as black, blue, or brown discoloration of the eschar.

NURSESLABS-BURNINJURY-05-013

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

A. Changing gloves between wound care on different parts of the client’s body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.

Correct Answer: A. Changing gloves between wound care on different parts of the client’s body.

Option B: Although all techniques listed can help reduce the risk of infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
Option C: Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). This identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
Option D: Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. This prevents cross-contamination and reduces the risk of acquired infection.

NURSESLABS-BURNINJURY-05-014

When should ambulation be initiated in the client who has sustained a major burn?

A. When all full-thickness areas have been closed with skin grafts
B. When the client’s temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after the resolution of the fluid shift

Correct Answer: D. As soon as possible after the resolution of the fluid shift

Regular, progressive ambulation is initiated for all burn clients who do not have contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.

Option A: The consistent finding in the literature is that early ambulation can be safely initiated after lower extremity skin grafting without compromising graft take if external compression is applied.
Option B: Following thermal injury, the innate immune system responds immediately by stimulating localized and systemic inflammatory reactions. The innate immune response participates in activating the adaptive immune response; however, in so doing it has an adverse effect on the burn victim’s ability to mount a vigorous immune response to invading microorganisms and, therefore, predisposes the burn victim to infectious complications.
Option C: Pain control is obtainable by performing therapies during wound dressing and debridement, if possible. Analgesics should also be administered prior to therapy sessions to encourage participation in movement activities.

NURSESLABS-BURNINJURY-05-015

What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?

A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
C. “I will have some scarring in the area when the skin is removed for grafting.”
D. “Once all grafting is completed, my risk for infection is the same as it was before I was burned.”

Correct Answer: B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”

Factors other than tissue type, such as circulation and infection, influence whether and how well a graft “takes.” The client should be prepared for the possibility that not all grafting procedures will be successful. Graft survival depends on the diffusion of nutrients and oxygen from the wound bed known as imbibition. Inosculation then follows when the blood vessels of the graft and from the wound bed grow together to make end-to-end contact. Lastly, neovascularization occurs when new blood vessels grow from the wound bed into the graft.

Option A: The donor sites will be painful after the surgery. Silicone gel sheets, along with pressure dressings, have shown a dramatic decrease in pain, pruritus, and scar thickness six months after burn injury.
Option C: There can be scarring in the area where the skin is removed for grafting. Burn scars are a common occurrence after skin grafting and can cause anxiety, depression, pain, itching, altered pigmentation, temperature intolerance, and decreased range of motion secondary to scar contracture. Scar formation is propagated by deficiencies in the biosynthetic and tissue degradation pathway during wound healing.
Option D: The client is still at risk for infection. Early failure of graft survival is attributable to seroma and hematoma formation, which lifts the graft off the wound bed, preventing imbibition. Other factors that lead to graft failure include shearing forces, edematous tissue, and infected tissue.

NURSESLABS-BURNINJURY-05-016

Which statement by the client indicates a correct understanding of rehabilitation after burn injury?

A. “I will never be fully recovered from the burn.”
B. “I am considered fully recovered when all the wounds are closed.”
C. “I will be fully recovered when I am able to perform all the activities I did before my injury.”
D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”

Correct Answer: D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”

Option A: Rehabilitation of burns patients is a continuum of active therapy starting from admission. There should be no delineation between an ‘acute phase’ and a ‘rehabilitation phase’ as this idea can promote the inequality of secondary disjointed scar management and/or functional rehabilitation teams.
Option B: The final stage in caring for a patient with a burn injury is the rehabilitative stage. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
Option C: Early compliance is essential to ensure the best possible long-term outcome and also to ease pain and assist with exercise regimes. Patients need to adhere to a positioning regime in the early stages of healing and this takes teamwork and dedication.

NURSESLABS-BURNINJURY-05-017

Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates a correct understanding of the purpose of this treatment?

A. “After this treatment, my ears will not stick out.”
B. “The mask will help protect my skin from sun damage.”
C. “Using this mask will prevent scars from being permanent.”
D. “My facial scars should be less severe with the use of this mask.”

Correct Answer: D. “My facial scars should be less severe with the use of this mask.”

Option A: The pressure garment will not change the angle of the ear attachment to the head. By applying pressure to the burn or scar, the face mask keeps the skin soft and flat during the scar-forming phase of healing. It helps the face heal with the least amount of scarring. The transparent face mask is worn 18-20 hours every day for 8 months to 2 years until the skin graft is mature.
Option B: Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy (PGT).
Option C: Scars will still be present. This treatment modality continues to be a clinically accepted practice. It is the most common therapy used for the treatment and prevention of abnormal scars after burn injury particularly in North America, Europe, and Scandinavia where it is considered routine practice and regarded as the preferred conservative management with reported thinning and better pliability ranging from 60% to 85%.

NURSESLABS-BURNINJURY-05-018

What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?

A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements

Correct Answer: B. Impaired Adjustment

Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the 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.

Option A: By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
Option C: Diversional activity for pain is applicable during the intermediate phase of the burn injury. Provide diversional activities appropriate for age and condition. This helps lessen concentration on pain experience and refocus attention.
Option D: Imbalanced nutrition is more appropriate during the emergent and intermediate phases of the burn injury. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As the burn wound heals, the percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.

NURSESLABS-BURNINJURY-05-019

Nurse Faith should recognize that fluid shift in a client with burn injury results from an increase in the:

A. Total volume of circulating whole blood
B. Total volume of intravascular plasma
C. Permeability of capillary walls
D. Permeability of kidney tubules

Correct Answer: C. Permeability of capillary walls

In burn, the capillaries and small vessels dilate, and cell damage causes the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.

Option A: The steady intravascular fluid loss due to these sequences of events requires sustained replacement of intravascular volume in order to prevent end-organ hypoperfusion and ischemia. Reduced cardiac output is a hallmark in this early post-injury phase.
Option B: Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces. Subsequently, intravascular hypovolemia and haemoconcentration develop and maximum levels are reached within 12 hours after injury.
Option D: Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability.

NURSESLABS-BURNINJURY-05-020

Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:

A. Maintain room humidity below 40%
B. Place top sheet on the client
C. Limit the occurrence of drafts
D. Keep room temperature at 80 degrees

Correct Answer: C. Limit the occurrence of drafts

A client with burns is very sensitive to temperature changes because heat is lost in the burn areas. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.

Option A: Maintain comfortable environmental temperature, provide heat lamps, heat-retaining body coverings. Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
Option B: Cover wounds as soon as possible unless open-air exposure burn care method is required. Temperature changes and air movement can cause great pain to exposed nerve endings.
Option D: The major burn patient needs a body temperature greater than 37 – 37.5ºC to reach 38.5ºC, to avoid critical temperature and decrease energy expenditure, controlling hypercatabolic state. The recommended ambient temperature in large burn units is between 28 and 33ºC.