Burns NCLEX Question and Burn
Injury Nursing Management (Part 2:
20 Items)
1. Question
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?
o A. Administer the prescribed tetanus toxoid vaccine.
o B. Assess wounds for signs of infection.
o C. Encourage the client to cough and breathe deeply.
o 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.
,2. 2. Question
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.
3. 3. Question
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 the 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.
4. 4. Question
What intervention will the nurse implement to reduce a client’s
pain after a burn injury?
A. Administering morphine 4 mg intravenously.
Injury Nursing Management (Part 2:
20 Items)
1. Question
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?
o A. Administer the prescribed tetanus toxoid vaccine.
o B. Assess wounds for signs of infection.
o C. Encourage the client to cough and breathe deeply.
o 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.
,2. 2. Question
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.
3. 3. Question
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 the 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.
4. 4. Question
What intervention will the nurse implement to reduce a client’s
pain after a burn injury?
A. Administering morphine 4 mg intravenously.
