NCLEX Style Practice Questions
Burns, Med Surg - Burns NCLEX
Review Questions, Med Surg Exam 3
Burns Questions, Med Surg : Chapter
25 Burns
Save
Terms in this set (100)
A 25-year-old patient is Correct Answer: 1
admitted with partial- Rationale 1: A moderate burn is a partial-thickness
thickness injuries over injury that is between 15%-25% of total body
20% of the total body surface area in adults.
surface area involving
both lower legs. The
nurse would classify this
injury as being which of
the following?
1. a moderate burn
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn
A 70-year-old patient Correct Answer: 1
has experienced a Rationale: Older adults are especially prone to
sunburn over much of dehydration; therefore, increasing fluid intake is
the body. What self-care especially important. Other manifestations could
technique is MOST include nausea and vomiting. All the measures help
important to emphasize alleviate the manifestations of this minor burn which
to an older adult in include pain, skin redness, chills, and headache.
,An 80-kg patient with 600 mL
burns over 30% of total The Parkland formula states that patients should
body surface area receive 4 mL/kg/%TBSA burned during the first 24
(TBSA) is admitted to the hours. Half of the total volume is given in the first 8
burn unit. Using the hours and then the last half is given over 16 hours: 4
Parkland formula of 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in
mL/kg/%TBSA, what is the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
the IV infusion rate
(mL/hour) for lactated
Ringer's solution that the
nurse will administer
during the first 8 hours?
An 82-year-old patient is C. Install tap water anti-scald devices.
moving into an
independent living Installing tap water anti-scald devices will help
facility. What is the best prevent accidental scald burns that more easily
advice the nurse can occur in older people as their skin becomes drier
give to the family to help and the dermis thinner. Cooking for her may be
prevent this patient from needed at times of illness or in the future, but she is
being accidently burned moving to an independent living facility, so at this
in her new home? time she should not need this assistance. Stopping
her from smoking may be helpful to prevent burns
A. Cook for her. but may not be possible without the requirement
B. Stop her from by the facility. Using an open space heater would
smoking. increase her risk of being burned and would not be
C. Install tap water anti- encouraged.
scald devices.
D. Be sure she uses an
open space heater.
The ambulance reports D. No pain, waxy white skin, and no blanching with
that they are transporting pressure
a patient to the ED who
has experienced a full- With full-thickness burns, the nerves and
thickness thermal burn vasculature in the dermis are destroyed so there is
from a grill. What no pain, the tissue is dry and waxy-looking or may
manifestations should be charred, and there is no blanching with
the nurse expect? pressure. Severe pain, blisters, and blanching occur
with partial-thickness (deep, second-degree) burns.
A. Severe pain, blisters, Pain, minimal edema, blanching, and redness occur
and blanching with with partial-thickness (superficial, first-degree)
,The charge nurse ANS: A
observes the following Sterile gloves should be worn when applying
actions being taken by a medications or dressings to a burn. Hypothermia is
new nurse on the burn an indicator of possible sepsis, and cultures are
unit. Which action by the appropriate. Nondiabetic patients may require
new nurse would require insulin because stress and high calorie intake may
an intervention by the lead to temporary hyperglycemia. Fentanyl peaks 5
charge nurse? minutes after IV administration, and should be used
a. The new nurse uses just before and during dressing changes for pain
clean latex gloves when management
applying antibacterial
cream to a burn wound.
b. The new nurse obtains
burn cultures when the
patient has a
temperature of 95.2° F
(35.1° C).
c. The new nurse
administers PRN fentanyl
(Sublimaze) IV to a
patient 5 minutes before
a dressing change.
d. The new nurse calls
the health care provider
for a possible insulin
order when a
nondiabetic patient's
serum glucose is
elevated.
During the acute phase Correct Answer: 1,2,3,4
of burn treatment, Rationale: The goals of treatment for the acute
important goals of period include wound cleansing and healing; pain
patient care include relief; preventing infection; promoting nutrition;
which of the following? and splinting, positioning, and exercising affected
Select all that apply. joints. Assessment of home maintenance
1. providing for patient management is an important goal in the
comfort rehabilitative stage, not the acute stage.
2. preventing infection
3. providing adequate
nutrition for healing to
occur
, During the care of the B. Monitor for signs of complications.
patient with a burn in the
acute phase, which new Monitoring for complications (e.g., wound infection,
interventions should the pneumonia, contractures) is needed in the acute
nurse expect to do after phase. Fluid replacement occurs in the emergent
the patient progressed phase. Assessing and managing pain and anxiety
from the emergent occurs in the emergent and the acute phases.
phase? Discussing possible reconstructive surgeries is
done in the rehabilitation phase.
A. Begin IV fluid
replacement.
B. Monitor for signs of
complications.
C. Assess and manage
pain and anxiety.
D. Discuss possible
reconstructive surgery.
During the emergent ANS: D
phase of burn care, When fluid intake is adequate, the urine output will
which assessment will be be at least 0.5 to 1 mL/kg/hour. The patient's weight
most useful in is not useful in this situation because of the effects
determining whether the of third spacing and evaporative fluid loss. Mucous
patient is receiving membrane assessment and skin turgor also may be
adequate fluid infusion? used, but they are not as adequate in determining
a. Check skin turgor. that fluid infusions are maintaining adequate
b. Monitor daily weight. perfusion.
c. Assess mucous
membranes.
d. Measure hourly urine
output.
Eight hours after a ANS: D
thermal burn covering The urine output should be at least 0.5 to 1.0
50% of a patient's total mL/kg/hr during the emergent phase, when the
body surface area patient is at great risk for hypovolemic shock. The
(TBSA) the nurse nurse should notify the health care provider
assesses the patient. because a higher IV fluid rate is needed. BP during
Which information would the emergent phase should be greater than 90
be a priority to systolic, and the pulse rate should be less than 120.
communicate to the Serous exudate from the burns is expected during
health care provider? the emergent phase
Burns, Med Surg - Burns NCLEX
Review Questions, Med Surg Exam 3
Burns Questions, Med Surg : Chapter
25 Burns
Save
Terms in this set (100)
A 25-year-old patient is Correct Answer: 1
admitted with partial- Rationale 1: A moderate burn is a partial-thickness
thickness injuries over injury that is between 15%-25% of total body
20% of the total body surface area in adults.
surface area involving
both lower legs. The
nurse would classify this
injury as being which of
the following?
1. a moderate burn
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn
A 70-year-old patient Correct Answer: 1
has experienced a Rationale: Older adults are especially prone to
sunburn over much of dehydration; therefore, increasing fluid intake is
the body. What self-care especially important. Other manifestations could
technique is MOST include nausea and vomiting. All the measures help
important to emphasize alleviate the manifestations of this minor burn which
to an older adult in include pain, skin redness, chills, and headache.
,An 80-kg patient with 600 mL
burns over 30% of total The Parkland formula states that patients should
body surface area receive 4 mL/kg/%TBSA burned during the first 24
(TBSA) is admitted to the hours. Half of the total volume is given in the first 8
burn unit. Using the hours and then the last half is given over 16 hours: 4
Parkland formula of 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in
mL/kg/%TBSA, what is the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
the IV infusion rate
(mL/hour) for lactated
Ringer's solution that the
nurse will administer
during the first 8 hours?
An 82-year-old patient is C. Install tap water anti-scald devices.
moving into an
independent living Installing tap water anti-scald devices will help
facility. What is the best prevent accidental scald burns that more easily
advice the nurse can occur in older people as their skin becomes drier
give to the family to help and the dermis thinner. Cooking for her may be
prevent this patient from needed at times of illness or in the future, but she is
being accidently burned moving to an independent living facility, so at this
in her new home? time she should not need this assistance. Stopping
her from smoking may be helpful to prevent burns
A. Cook for her. but may not be possible without the requirement
B. Stop her from by the facility. Using an open space heater would
smoking. increase her risk of being burned and would not be
C. Install tap water anti- encouraged.
scald devices.
D. Be sure she uses an
open space heater.
The ambulance reports D. No pain, waxy white skin, and no blanching with
that they are transporting pressure
a patient to the ED who
has experienced a full- With full-thickness burns, the nerves and
thickness thermal burn vasculature in the dermis are destroyed so there is
from a grill. What no pain, the tissue is dry and waxy-looking or may
manifestations should be charred, and there is no blanching with
the nurse expect? pressure. Severe pain, blisters, and blanching occur
with partial-thickness (deep, second-degree) burns.
A. Severe pain, blisters, Pain, minimal edema, blanching, and redness occur
and blanching with with partial-thickness (superficial, first-degree)
,The charge nurse ANS: A
observes the following Sterile gloves should be worn when applying
actions being taken by a medications or dressings to a burn. Hypothermia is
new nurse on the burn an indicator of possible sepsis, and cultures are
unit. Which action by the appropriate. Nondiabetic patients may require
new nurse would require insulin because stress and high calorie intake may
an intervention by the lead to temporary hyperglycemia. Fentanyl peaks 5
charge nurse? minutes after IV administration, and should be used
a. The new nurse uses just before and during dressing changes for pain
clean latex gloves when management
applying antibacterial
cream to a burn wound.
b. The new nurse obtains
burn cultures when the
patient has a
temperature of 95.2° F
(35.1° C).
c. The new nurse
administers PRN fentanyl
(Sublimaze) IV to a
patient 5 minutes before
a dressing change.
d. The new nurse calls
the health care provider
for a possible insulin
order when a
nondiabetic patient's
serum glucose is
elevated.
During the acute phase Correct Answer: 1,2,3,4
of burn treatment, Rationale: The goals of treatment for the acute
important goals of period include wound cleansing and healing; pain
patient care include relief; preventing infection; promoting nutrition;
which of the following? and splinting, positioning, and exercising affected
Select all that apply. joints. Assessment of home maintenance
1. providing for patient management is an important goal in the
comfort rehabilitative stage, not the acute stage.
2. preventing infection
3. providing adequate
nutrition for healing to
occur
, During the care of the B. Monitor for signs of complications.
patient with a burn in the
acute phase, which new Monitoring for complications (e.g., wound infection,
interventions should the pneumonia, contractures) is needed in the acute
nurse expect to do after phase. Fluid replacement occurs in the emergent
the patient progressed phase. Assessing and managing pain and anxiety
from the emergent occurs in the emergent and the acute phases.
phase? Discussing possible reconstructive surgeries is
done in the rehabilitation phase.
A. Begin IV fluid
replacement.
B. Monitor for signs of
complications.
C. Assess and manage
pain and anxiety.
D. Discuss possible
reconstructive surgery.
During the emergent ANS: D
phase of burn care, When fluid intake is adequate, the urine output will
which assessment will be be at least 0.5 to 1 mL/kg/hour. The patient's weight
most useful in is not useful in this situation because of the effects
determining whether the of third spacing and evaporative fluid loss. Mucous
patient is receiving membrane assessment and skin turgor also may be
adequate fluid infusion? used, but they are not as adequate in determining
a. Check skin turgor. that fluid infusions are maintaining adequate
b. Monitor daily weight. perfusion.
c. Assess mucous
membranes.
d. Measure hourly urine
output.
Eight hours after a ANS: D
thermal burn covering The urine output should be at least 0.5 to 1.0
50% of a patient's total mL/kg/hr during the emergent phase, when the
body surface area patient is at great risk for hypovolemic shock. The
(TBSA) the nurse nurse should notify the health care provider
assesses the patient. because a higher IV fluid rate is needed. BP during
Which information would the emergent phase should be greater than 90
be a priority to systolic, and the pulse rate should be less than 120.
communicate to the Serous exudate from the burns is expected during
health care provider? the emergent phase
