BURNS NCLEX QUESTION AND BURN
INJURY NURSING MANAGEMENT
(PART 4: 20 ITEMS)
1. Question
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?
o A. Superficial
o B. Partial-thickness superficial
o C. Partial-thickness deep
o 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.
2. 2. Question
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.
3. 3. Question
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
INJURY NURSING MANAGEMENT
(PART 4: 20 ITEMS)
1. Question
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?
o A. Superficial
o B. Partial-thickness superficial
o C. Partial-thickness deep
o 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.
2. 2. Question
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.
3. 3. Question
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
