Burn Injury Nursing Management NCLEX Practice Quiz #2 (20 Questions)

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Burn Injury Nursing Management NCLEX Practice Quiz #2 (20 Questions)

If you are about to take the NCLEX, questions about burn injury and its management always has its own space. Basically, these questions are relatively not hard to handle as long as you know the concepts about burns. Equip yourself with the right knowledge with this 20-item practice exam about burns.

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Topics

Included topics in this practice quiz are:

Guidelines

Follow the guidelines below to make the most out of this exam:

  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.

Questions

Exam Mode

In Exam Mode: All questions are shown in random and the results, answers and rationales (if any) will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 20 minutes in this quiz.

NCLEX Exam: Burn Injury Nursing Management 2 (20 Items)

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Practice Mode

Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.

NCLEX Exam: Burn Injury Nursing Management 2 (20 Items)

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Text Mode

1. 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.

2. Three days after a burn injury, the client develops a temperature of 100° F, 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

3. 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

4. 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

5. What statement indicates the client needs further education regarding the 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.”

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

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

7. Which assessment finding assists the nurse in confirming inhalation injury?

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

8. 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

9. 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

10. 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.”

11. 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

12. 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

13. 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)

14. 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

15. 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.”

16. 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.”

17. 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.

18. 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

19. 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.

20. 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

Answers and Rationale

1. 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. Although all the interventions listed can help reduce the risk for infection, hand washing is the most effective technique for preventing infection transmission.

2. Answer: D. Wound infection 

Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.

3. 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.

4. Answer: A. Administering morphine 4 mg intravenously.

Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with
absorption from the muscle and stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering, the room must be kept warm and heat should be applied.

5. 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. The donor sites will be painful after the surgery, there can be scarring in the area where skin is removed for grafting, and the client is still at risk for infection.

6. 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. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

7. Answer: A. Brassy cough

Brassy cough and wheezing are some signs seen with inhalation injury. All the other symptoms are seen with carbon monoxide poisoning.

8. 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.

9. Answer: C. Performing his own morning care

Indicators that the client with a burn injury has a positive perception of his appearance includes 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. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications, but will not increase self-perception.

10. 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. 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.

11. 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. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.

12. 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. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However, these are not priority diagnoses at this time.

13. 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 for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal, but not to the same degree of severity, and would be expected in the emergent phase after a burn injury.

14. 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. The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.

15. 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.

16. 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. Scars will still be present. Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose for wearing the mask. The pressure garment will not alter the risk for infection.

17. 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.

18. 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.

19. Answer: A.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. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

20. 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.

See Also


You may also like these other quizzes and exam tip articles:

Study Guides


Cardiovascular System


Respiratory System


Nervous System


Digestive and Gastrointestinal System


Endocrine System


Urinary System


Homeostasis: Fluids and Electrolytes


Cancer and Oncology Nursing


Burns and Burn Injury Management

Emergency Nursing


Miscellaneous


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Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on difficult nursing topics and finding help online is near to impossible. His situation drove his passion for helping student nurses through the creation of content and lectures that is easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire students in nursing. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, breakdown complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing concepts effectively.

1 COMMENT

  1. Question 5: an “Allograft” is not the same as an “autograft.” This question’s answer refers to an autogtraft, which requires adonor site. Allografting in this situation is cadaver skin, as the allograft will come from the same species. This is the first step in burn grafting and is meant as protection until the body sloughs it off and the patient is stable enough to provide an autograft.

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