1|Page
BURNS NCLEX QUESTIONS AND VERIFIED
CORRECT ANSWERS
NEWLY FORMATTED DOCUMENT
When assessing a patient who ANS: B
spilled hot oil on the right leg With full-thickness skin destruction, the appearance is pale and dry
and foot, the or leathery and the area is painless because of the associated
nurse notes that the skin is dry, nerve destruction.
pale, hard skin. The patient states Erythema, swelling, and blisters point to a deep partial-
that the burn is not painful. What thickness burn. With superficial partial- thickness burns, the
term would the nurse use to area is red, but no blisters are present. First-degree burns
document the burn depth? exhibit erythema, blanching, and pain.
a. First-degree skin
destruction
b. Full-thickness skin
destruction
c. Deep partial-thickness skin
destruction
d. Superficial partial-
thickness skin destruction
,2|Page
On admission to the burn ANS: C
unit, a patient with an The patient's laboratory data show
approximate 25% total hemoconcentration, which may lead to a decrease in
body surface area (TBSA) blood flow to the microcirculation unless fluid intake
burn has the following is increased. Because the hematocrit and hemoglobin
initial laboratory results: are elevated, a transfusion is inappropriate, although
Hct 58%, Hgb 18.2 mg/dL transfusions may be needed after the emergent phase
(172 g/L), serum K+ 4.9 once the patient's fluid balance has been restored. On
mEq/L (4.8 mmol/L), and admission to a burn unit, the urine output would be
serum Na+ 135 mEq/L (135 monitored more often than every 4 hours; likely
mmol/L). Which action will every1 hour.
the nurse anticipate taking
now?
a. Monitor urine output
every 4 hours.
b. Continue to monitor the
laboratory results.
c. Increase the rate of the
ordered IV solution.
d. Type and crossmatch
for a blood transfusion.
,3|Page
A patient is admitted to the ANS: B
burn unit with burns to the head, The patient's history and clinical manifestations suggest airway
face, and hands. edema and the health care provider should be notified
Initially, wheezes are immediately, so that intubation can be done rapidly. Placing the
heard, but an hour later, the lung patient in a more upright position or having the patient cough will
sounds are not address the problem of airway edema. Continuing to monitor
decreased and no wheezes are is inappropriate because immediate action should
audible. What is the best action occur.
for the
nurse to take?
a. Encourage the patient to
cough and auscultate the
lungs again.
b. Notify the health care
provider and prepare for
endotracheal intubation.
c. Document the results and
continue to monitor the
patient's respiratory rate.
d. Reposition the patient in high-
Fowler's position and reassess
breath sounds.
, 4|Page
A patient with severe ANS: C
burns has crystalloid fluid Half of the fluid replacement using the Parkland
replacement ordered formula is administered in the first 8 hours and the
using the Parkland other half over the next 16 hours. In this case, the
formula. The initial volume patient should receive half of the initial rate, or 938
of fluid to be administered mL/hr.
in the first 24 hours is
30,000 mL. The initial rate
of administration is 1875
mL/hr. After the first 8
hours, what rate should
the nurse infuse the IV
fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour
During the emergent ANS: D
phase of burn care, which When fluid intake is adequate, the urine output will be
assessment will be most at least 0.5 to 1 mL/kg/hour. The patient's weight is not
useful in determining useful in this situation because of the effects of third
whether the patient is spacing and evaporative fluid loss. Mucous
receiving adequate fluid membrane assessment and skin turgor also may be
infusion? used, but they are not as adequate in determining that
a. Check skin turgor. fluid infusions are maintaining adequate perfusion.
b. Monitor daily weight.
c. Assess mucous
membranes.
d. Measure hourly urine
output.
BURNS NCLEX QUESTIONS AND VERIFIED
CORRECT ANSWERS
NEWLY FORMATTED DOCUMENT
When assessing a patient who ANS: B
spilled hot oil on the right leg With full-thickness skin destruction, the appearance is pale and dry
and foot, the or leathery and the area is painless because of the associated
nurse notes that the skin is dry, nerve destruction.
pale, hard skin. The patient states Erythema, swelling, and blisters point to a deep partial-
that the burn is not painful. What thickness burn. With superficial partial- thickness burns, the
term would the nurse use to area is red, but no blisters are present. First-degree burns
document the burn depth? exhibit erythema, blanching, and pain.
a. First-degree skin
destruction
b. Full-thickness skin
destruction
c. Deep partial-thickness skin
destruction
d. Superficial partial-
thickness skin destruction
,2|Page
On admission to the burn ANS: C
unit, a patient with an The patient's laboratory data show
approximate 25% total hemoconcentration, which may lead to a decrease in
body surface area (TBSA) blood flow to the microcirculation unless fluid intake
burn has the following is increased. Because the hematocrit and hemoglobin
initial laboratory results: are elevated, a transfusion is inappropriate, although
Hct 58%, Hgb 18.2 mg/dL transfusions may be needed after the emergent phase
(172 g/L), serum K+ 4.9 once the patient's fluid balance has been restored. On
mEq/L (4.8 mmol/L), and admission to a burn unit, the urine output would be
serum Na+ 135 mEq/L (135 monitored more often than every 4 hours; likely
mmol/L). Which action will every1 hour.
the nurse anticipate taking
now?
a. Monitor urine output
every 4 hours.
b. Continue to monitor the
laboratory results.
c. Increase the rate of the
ordered IV solution.
d. Type and crossmatch
for a blood transfusion.
,3|Page
A patient is admitted to the ANS: B
burn unit with burns to the head, The patient's history and clinical manifestations suggest airway
face, and hands. edema and the health care provider should be notified
Initially, wheezes are immediately, so that intubation can be done rapidly. Placing the
heard, but an hour later, the lung patient in a more upright position or having the patient cough will
sounds are not address the problem of airway edema. Continuing to monitor
decreased and no wheezes are is inappropriate because immediate action should
audible. What is the best action occur.
for the
nurse to take?
a. Encourage the patient to
cough and auscultate the
lungs again.
b. Notify the health care
provider and prepare for
endotracheal intubation.
c. Document the results and
continue to monitor the
patient's respiratory rate.
d. Reposition the patient in high-
Fowler's position and reassess
breath sounds.
, 4|Page
A patient with severe ANS: C
burns has crystalloid fluid Half of the fluid replacement using the Parkland
replacement ordered formula is administered in the first 8 hours and the
using the Parkland other half over the next 16 hours. In this case, the
formula. The initial volume patient should receive half of the initial rate, or 938
of fluid to be administered mL/hr.
in the first 24 hours is
30,000 mL. The initial rate
of administration is 1875
mL/hr. After the first 8
hours, what rate should
the nurse infuse the IV
fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour
During the emergent ANS: D
phase of burn care, which When fluid intake is adequate, the urine output will be
assessment will be most at least 0.5 to 1 mL/kg/hour. The patient's weight is not
useful in determining useful in this situation because of the effects of third
whether the patient is spacing and evaporative fluid loss. Mucous
receiving adequate fluid membrane assessment and skin turgor also may be
infusion? used, but they are not as adequate in determining that
a. Check skin turgor. fluid infusions are maintaining adequate perfusion.
b. Monitor daily weight.
c. Assess mucous
membranes.
d. Measure hourly urine
output.
