NCLEX Style Practice Questions Burns, Med Surg - Burns
NCLEX Review Questions, Med Surg Exam 3 Burns
Questions, Med Surg : Chapter 25 Burns
When assessing a patient who spilled hot oil on the right leg and foot,
the nurse notes that the skin is dry, pale, hard skin. The patient states
that the burn is not painful. What term would the nurse use to
document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - CORRECT ANSWER
>>>>>ANS: B
With full-thickness skin destruction, the appearance is pale and dry or
leathery and the area is painless because of the associated nerve
destruction. Erythema, swelling, and blisters point to a deep partial-
thickness burn. With superficial partial-thickness burns, the area is
red, but no blisters are present. First-degree burns exhibit erythema,
blanching, and pain
On admission to the burn unit, a patient with an approximate 25%
total body surface area (TBSA) burn has the following initial
laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9
mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which
action will 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. - CORRECT ANSWER
>>>>>ANS: C
The patient's laboratory data show hemoconcentration, which may
lead to a decrease in blood flow to the microcirculation unless fluid
intake is increased. Because the hematocrit and hemoglobin are
elevated, a transfusion is inappropriate, although transfusions may be
needed after the emergent phase once the patient's fluid balance has
been restored. On admission to a burn unit, the urine output would
be monitored more often than every 4 hours; likely every1 hour.
A patient is admitted to the burn unit with burns to the head, face,
and hands. Initially, wheezes are heard, but an hour later, the lung
sounds are decreased and no wheezes are audible. What is the best
action 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. - CORRECT ANSWER >>>>>ANS: B
The patient's history and clinical manifestations suggest airway
edema and the health care provider should be notified immediately,
so that intubation can be done rapidly. Placing the patient in a more
upright position or having the patient cough will not address the
,problem of airway edema. Continuing to monitor is inappropriate
because immediate action should occur
A patient with severe burns has crystalloid fluid replacement ordered
using the Parkland formula. The initial volume of fluid to be
administered 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 - CORRECT ANSWER >>>>>ANS: C
Half of the fluid replacement using the Parkland formula is
administered in the first 8 hours and the other half over the next 16
hours. In this case, the patient should receive half of the initial rate, or
938 mL/hr.
During the emergent phase of burn care, which assessment will be
most useful in determining whether the patient is receiving adequate
fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - CORRECT ANSWER >>>>>ANS: D
, When fluid intake is adequate, the urine output will be at least 0.5 to
1 mL/kg/hour. The patient's weight is not useful in this situation
because of the effects of third spacing and evaporative fluid loss.
Mucous membrane assessment and skin turgor also may be used, but
they are not as adequate in determining that fluid infusions are
maintaining adequate perfusion.
A patient has just been admitted with a 40% total body surface area
(TBSA) burn injury. To maintain adequate nutrition, the nurse should
plan to take which action?
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. -
CORRECT ANSWER >>>>>ANS: A
Enteral feedings can usually be initiated during the emergent phase at
low rates and increased over 24 to 48 hours to the goal rate. During
the emergent phase, the patient will be unable to eat enough calories
to meet nutritional needs and may have a paralytic ileus that prevents
adequate nutrient absorption. Vitamins and minerals may be
administered during the emergent phase, but these will not assist in
meeting the patient's caloric needs. Parenteral nutrition increases the
infection risk, does not help preserve gastrointestinal function, and is
not routinely used in burn patients.
NCLEX Review Questions, Med Surg Exam 3 Burns
Questions, Med Surg : Chapter 25 Burns
When assessing a patient who spilled hot oil on the right leg and foot,
the nurse notes that the skin is dry, pale, hard skin. The patient states
that the burn is not painful. What term would the nurse use to
document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - CORRECT ANSWER
>>>>>ANS: B
With full-thickness skin destruction, the appearance is pale and dry or
leathery and the area is painless because of the associated nerve
destruction. Erythema, swelling, and blisters point to a deep partial-
thickness burn. With superficial partial-thickness burns, the area is
red, but no blisters are present. First-degree burns exhibit erythema,
blanching, and pain
On admission to the burn unit, a patient with an approximate 25%
total body surface area (TBSA) burn has the following initial
laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9
mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which
action will 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. - CORRECT ANSWER
>>>>>ANS: C
The patient's laboratory data show hemoconcentration, which may
lead to a decrease in blood flow to the microcirculation unless fluid
intake is increased. Because the hematocrit and hemoglobin are
elevated, a transfusion is inappropriate, although transfusions may be
needed after the emergent phase once the patient's fluid balance has
been restored. On admission to a burn unit, the urine output would
be monitored more often than every 4 hours; likely every1 hour.
A patient is admitted to the burn unit with burns to the head, face,
and hands. Initially, wheezes are heard, but an hour later, the lung
sounds are decreased and no wheezes are audible. What is the best
action 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. - CORRECT ANSWER >>>>>ANS: B
The patient's history and clinical manifestations suggest airway
edema and the health care provider should be notified immediately,
so that intubation can be done rapidly. Placing the patient in a more
upright position or having the patient cough will not address the
,problem of airway edema. Continuing to monitor is inappropriate
because immediate action should occur
A patient with severe burns has crystalloid fluid replacement ordered
using the Parkland formula. The initial volume of fluid to be
administered 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 - CORRECT ANSWER >>>>>ANS: C
Half of the fluid replacement using the Parkland formula is
administered in the first 8 hours and the other half over the next 16
hours. In this case, the patient should receive half of the initial rate, or
938 mL/hr.
During the emergent phase of burn care, which assessment will be
most useful in determining whether the patient is receiving adequate
fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - CORRECT ANSWER >>>>>ANS: D
, When fluid intake is adequate, the urine output will be at least 0.5 to
1 mL/kg/hour. The patient's weight is not useful in this situation
because of the effects of third spacing and evaporative fluid loss.
Mucous membrane assessment and skin turgor also may be used, but
they are not as adequate in determining that fluid infusions are
maintaining adequate perfusion.
A patient has just been admitted with a 40% total body surface area
(TBSA) burn injury. To maintain adequate nutrition, the nurse should
plan to take which action?
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. -
CORRECT ANSWER >>>>>ANS: A
Enteral feedings can usually be initiated during the emergent phase at
low rates and increased over 24 to 48 hours to the goal rate. During
the emergent phase, the patient will be unable to eat enough calories
to meet nutritional needs and may have a paralytic ileus that prevents
adequate nutrient absorption. Vitamins and minerals may be
administered during the emergent phase, but these will not assist in
meeting the patient's caloric needs. Parenteral nutrition increases the
infection risk, does not help preserve gastrointestinal function, and is
not routinely used in burn patients.
