Chapter 25 Burns NCLEX style questions with rationales 2025
When assessing a patient with a partial-thickness burn, the nurse
would expect to find (SATA): Correct answers: a, d, e
a. blisters Rationale: The appearance of partial-thickness (deep) burns may
b. exposed fascia include fluid-filled vesicles (blisters) that are red, shiny, or wet (if
c. exposed muscles vesicles have ruptured). Patients may have severe pain caused by
d. intact nerve endings exposure of nerve endings and may have mild to moderate edema.
e. red, shiny, wet appearance
A patient is admitted to the burn center with burns of his head and
neck, chest, and back after an explosion in his garage. On assess-
ment, the nurse auscultates wheezes throughout the lung fields.
On reassessment, the wheezes are gone and the breath sounds Correct answer: d
are greatly diminished. Which action is the most appropriate for
the nurse to take next? Rationale: Inhalation injury results in exposure of the respiratory
tract to intense heat or flames with inhalation of noxious chemicals,
a. obtain vital signs and a STAT ABG smoke, or carbon monoxide. The nurse should anticipate the need
b. encourage the patient to cough and auscultate the lungs again for intubation and mechanical ventilation because this patient is
c. document the findings and continue to monitor the patient's demonstrating signs of severe respiratory distress.
breathing
d. anticipate the need for endotracheal intubation and notify the
physician
Fluid and electrolyte shifts that occur during the early emergent
phase of a burn injury include:
Correct answer: c
a. adherence of albumin to vascular walls
Rationale: During the emergency phase, sodium rapidly shifts to
b. movement of potassium into vascular space
the interstitial spaces and remains there until edema formation
c. sequestering of sodium and water in interstitial fluid
ceases.
d. hemolysis of red blood cells from large volumes of rapidly
administered fluid
To maintain a positive nitrogen balance in a major burn, the patient Correct answer: a
must:
Rationale: The patient should be encouraged to eat high-protein,
a. eat a high-protein, low-fat, high-carbohydrate diet
high-carbohydrate foods to meet increased caloric needs. Massive
b. increase normal caloric intake by about three times
catabolism can occur and is characterized by protein breakdown
c. eat at least 1500 calories/day in small, frequent meals
and increased gluconeogenesis. Failure to supply adequate calo-
d. eat rice and whole wheat for the chemical effect on nitrogen
ries and protein leads to malnutrition and delays in healing.
balance.
A patient has 25% TBSA burned 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
Correct answer: b
b. observe the wound for signs of infection during dressing
Rationale: Infection is the most serious threat with regard to further
changes
tissue injury and possible sepsis.
c. apply cool compresses for pain relief in between dressing
changes
d. wash the wound aggressively with soap and water three times
a day.
Correct answers: a, c, d
Pain management for the burn patient is most effective when
(SATA): Rationale: The use of a pain rating tool assists the nurse in the
assessment, monitoring, and evaluation of the pain management
a. a pain rating tool is used to monitor the patient's level of pain
plan. The more control the patient has in managing the pain, the
b. painful dressing changes are delayed until the patient's pain is
more successful the chosen strategies are. A selected variety of
completely relieved
medications offer better pain relief for patients with burns, whose
c. the patient is informed about and has some control over the
pain can be both continuous and treatment related over varying
management of the pain
periods of time. It is not realistic to promise a patient that pain will
d. a multi-modal approach is used (e.g., sustained-release and
be completely eliminated. It is not realistic to suggest that pain
short-acting opioids, NSAIDS, adjuvant analgesics).
e. will be managed (during any phase of burn care) with nonphar-
non-pharmacological therapies (e.g., music therapy, distraction)
macologic pain management. Such management is meant to be
replace opioids in the rehabilitation phase of a burn injury
adjuvant and individualized.
1/4
When assessing a patient with a partial-thickness burn, the nurse
would expect to find (SATA): Correct answers: a, d, e
a. blisters Rationale: The appearance of partial-thickness (deep) burns may
b. exposed fascia include fluid-filled vesicles (blisters) that are red, shiny, or wet (if
c. exposed muscles vesicles have ruptured). Patients may have severe pain caused by
d. intact nerve endings exposure of nerve endings and may have mild to moderate edema.
e. red, shiny, wet appearance
A patient is admitted to the burn center with burns of his head and
neck, chest, and back after an explosion in his garage. On assess-
ment, the nurse auscultates wheezes throughout the lung fields.
On reassessment, the wheezes are gone and the breath sounds Correct answer: d
are greatly diminished. Which action is the most appropriate for
the nurse to take next? Rationale: Inhalation injury results in exposure of the respiratory
tract to intense heat or flames with inhalation of noxious chemicals,
a. obtain vital signs and a STAT ABG smoke, or carbon monoxide. The nurse should anticipate the need
b. encourage the patient to cough and auscultate the lungs again for intubation and mechanical ventilation because this patient is
c. document the findings and continue to monitor the patient's demonstrating signs of severe respiratory distress.
breathing
d. anticipate the need for endotracheal intubation and notify the
physician
Fluid and electrolyte shifts that occur during the early emergent
phase of a burn injury include:
Correct answer: c
a. adherence of albumin to vascular walls
Rationale: During the emergency phase, sodium rapidly shifts to
b. movement of potassium into vascular space
the interstitial spaces and remains there until edema formation
c. sequestering of sodium and water in interstitial fluid
ceases.
d. hemolysis of red blood cells from large volumes of rapidly
administered fluid
To maintain a positive nitrogen balance in a major burn, the patient Correct answer: a
must:
Rationale: The patient should be encouraged to eat high-protein,
a. eat a high-protein, low-fat, high-carbohydrate diet
high-carbohydrate foods to meet increased caloric needs. Massive
b. increase normal caloric intake by about three times
catabolism can occur and is characterized by protein breakdown
c. eat at least 1500 calories/day in small, frequent meals
and increased gluconeogenesis. Failure to supply adequate calo-
d. eat rice and whole wheat for the chemical effect on nitrogen
ries and protein leads to malnutrition and delays in healing.
balance.
A patient has 25% TBSA burned 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
Correct answer: b
b. observe the wound for signs of infection during dressing
Rationale: Infection is the most serious threat with regard to further
changes
tissue injury and possible sepsis.
c. apply cool compresses for pain relief in between dressing
changes
d. wash the wound aggressively with soap and water three times
a day.
Correct answers: a, c, d
Pain management for the burn patient is most effective when
(SATA): Rationale: The use of a pain rating tool assists the nurse in the
assessment, monitoring, and evaluation of the pain management
a. a pain rating tool is used to monitor the patient's level of pain
plan. The more control the patient has in managing the pain, the
b. painful dressing changes are delayed until the patient's pain is
more successful the chosen strategies are. A selected variety of
completely relieved
medications offer better pain relief for patients with burns, whose
c. the patient is informed about and has some control over the
pain can be both continuous and treatment related over varying
management of the pain
periods of time. It is not realistic to promise a patient that pain will
d. a multi-modal approach is used (e.g., sustained-release and
be completely eliminated. It is not realistic to suggest that pain
short-acting opioids, NSAIDS, adjuvant analgesics).
e. will be managed (during any phase of burn care) with nonphar-
non-pharmacological therapies (e.g., music therapy, distraction)
macologic pain management. Such management is meant to be
replace opioids in the rehabilitation phase of a burn injury
adjuvant and individualized.
1/4
