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N E W O RI G I NA L [ 2 0 2 4 - 2 0 2 5 E XA M #3 ( B UR NS
N C LE X ) G UA R ANT E E PASS E X AM]
a The injury that is least likely to result in a full-thickness burn is a. sunburn b. scald injury c. chemical burn d. electrical injury a d e When assessing a patient with a partial-thickness burn, the nurse would expect to find Select all that apply a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance d A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultated
wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. encourage the patient to cough and auscultate the lungs again b. obtain vital signs, oxygen saturation, and a STAT ABG c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician c Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls b. movement of potassium into the vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of RBC from large volumes of rapidly administered fluid a To maintain a positive nitrogen balance in a major burn area, the patient must a. eat a high-protein, high-carbohydrate diet b. increase normal caloric intake by about three times c. eat at least 1500 calories/day in small, frequent meals d. eat a gluten-free diet for the chemical effect on nitrogen balance b A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief between dressing changes
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods c When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. Mannitol 75 g IV b. Urine for myoglobulin c. Lactated Ringer's solution at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours c An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? a. Cook for her. b. Stop her from smoking. c. Install tap water anti-scald devices. d. Be sure she uses an open space heater. d A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? a. Severe pain, blisters, and blanching with pressure b. Pain, minimal edema, and blanching with pressure
c. Redness, evidence of inhalation injury, and charred skin d. No pain, waxy white skin, and no blanching with pressure d In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? a. Serum sodium and potassium increase. b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases. b The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? a. Begin IV fluid replacement. b. Monitor for signs of complications. c. Assess and manage pain and anxiety. d. Discuss possible reconstructive surgery. c A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? a. Replace the blood lost. b. Maintain a neutral pH. c. Maintain fluid balance. d. Replace serum potassium. a A patient with a burn inhalation injury is receiving albuterol for the treatment of
d. Assist the patient to a high Fowler's position. b The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? a. Skin is hard with a dry, waxy white appearance. b. Skin is shiny and red with clear, fluid-filled blisters. c. Skin is red and blanches when slight pressure is applied. d. Skin is leathery with visible muscles, tendons, and bones. a The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? a. Morphine b. Sertraline c. Zolpidem d. Enoxaparin a c d e The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care? Select all that apply a. Escharotomy b. Administration of diuretics c. IV and oral pain medications
d. Daily cleansing and debridement e. Application of topical antimicrobial agent a b c e A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? Select all that apply a. Singed nasal hair b. Generalized pallor c. Painful swallowing d. Burns on the upper extremities e. History of being involved in a large fire b c When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply a. The exercises are the only way to prevent contractures. b. Active and passive ROM maintain function of body parts. c. ROM will show the patient that movement is still possible d. Movement facilitates mobilization of leaked exudates back into the vascular bed. e. Active and passive ROM can only be done while the dressings are being changed. a b The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn
c. Assess mucous membranes. d. Measure hourly urine output. a To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to a. insert a feeding tube and initiate enteral feedings. b. infuse total parenteral nutrition via a central catheter. c. encourage an oral intake of at least 5000 kcal per day. d. administer multiple vitamins and minerals in the IV solution. b A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will be included in the plan of care? a. Restrict all visitors to prevent cross-contamination of wounds. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Turn the room temperature up to at least 68 F (20 C) during dressing changes. d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds. b Which action will be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck. a A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take?
a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both arms above heart level with pillows. d. Encourage the patient to flex and extend the fingers. d Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement? a. ketorolac (Toradol) b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid) c The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when a. white blood cell levels decrease. b. blisters and edema have subsided. c. the patient has large quantities of pale urine. d. the patient has been hospitalized for 48 hours. d Which of these snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment? a. Strawberry gelatin b. Whole wheat bagel c. Chunky applesauce d. Chocolate milkshake c
d. Administer the ordered opioid pain medications. b A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these prescribed interventions should the nurse implement first? a. Start two large bore IVs. b. Place on cardiac monitor. c. Apply dressings to burned areas. d. Assess for pain at contact points d Six hours after a thermal burn covering 50% of a patients total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider? a. Blood pressure is 94/46 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 104. d. Urine output is 20 mL per hour for the past 2 hours. b After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who has a dressing change scheduled d. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain
