Med-Surg Burns NCLEX Practice Questions and Answers 2026 |
Chapter 25 Burns, Exam 3 Review & Nursing Exam Prep
Whenxassessingxaxpatientxwhoxspilledxhotxoilxonxthexrightxlegxandxfoot,xthexnursexnotesxthatxthexskinxisx
dry,xpale,xhardxskin.xThexpatientxstatesxthatxthexburnxisxnotxpainful.xWhatxtermxwouldxthexnursexusextox
documentxthexburnxdepth?
a.xFirst-degreexskinxdestruction
b.xFull-thicknessxskinxdestruction
c.xDeepxpartial-thicknessxskinxdestruction
d.xSuperficialxpartial-thicknessxskinxdestructionx-xcorrectxanswerx ✅ANS:xB
Withxfull-
thicknessxskinxdestruction,xthexappearancexisxpalexandxdryxorxleatheryxandxthexareaxisxpainlessxbecausex
ofxthexassociatedxnervexdestruction.xErythema,xswelling,xandxblistersxpointxtoxaxdeepxpartial-
thicknessxburn.xWithxsuperficialxpartial-
thicknessxburns,xthexareaxisxred,xbutxnoxblistersxarexpresent.xFirst-
degreexburnsxexhibitxerythema,xblanching,xandxpain
Onxadmissionxtoxthexburnxunit,xaxpatientxwithxanxapproximatex25%xtotalxbodyxsurfacexareax(TBSA)xburn
xhasxthexfollowingxinitialxlaboratoryxresults:xHctx58%,xHgbx18.2xmg/dLx(172xg/L),xserumxK+x4.9xmEq/Lx(4.
8xmmol/L),xandxserumxNa+x135xmEq/Lx(135xmmol/L).xWhichxactionxwillxthexnursexanticipatextakingxnow
?
a.xMonitorxurinexoutputxeveryx4xhours.
b.xContinuextoxmonitorxthexlaboratoryxresults.
c.xIncreasexthexratexofxthexorderedxIVxsolution.
d.xTypexandxcrossmatchxforxaxbloodxtransfusion.x-xcorrectxanswerx ✅ANS:xC
Thexpatient'sxlaboratoryxdataxshowxhemoconcentration,xwhichxmayxleadxtoxaxdecreasexinxbloodxflowxto
xthexmicrocirculationxunlessxfluidxintakexisxincreased.xBecausexthexhematocritxandxhemoglobinxarexelev
ated,xaxtransfusionxisxinappropriate,xalthoughxtransfusionsxmayxbexneededxafterxthexemergentxphasexo
ncexthexpatient'sxfluidxbalancexhasxbeenxrestored.xOnxadmissionxtoxaxburnxunit,xthexurinexoutputxwould
xbexmonitoredxmorexoftenxthanxeveryx4xhours;xlikelyxevery1xhour.
Axpatientxisxadmittedxtoxthexburnxunitxwithxburnsxtoxthexhead,xface,xandxhands.xInitially,xwheezesxarexh
eard,xbutxanxhourxlater,xthexlungxsoundsxarexdecreasedxandxnoxwheezesxarexaudible.xWhatxisxthexbestxa
ctionxforxthexnursextoxtake?
a.xEncouragexthexpatientxtoxcoughxandxauscultatexthexlungsxagain.
,b.xNotifyxthexhealthxcarexproviderxandxpreparexforxendotrachealxintubation.
c.xDocumentxthexresultsxandxcontinuextoxmonitorxthexpatient'sxrespiratoryxrate.
d.xRepositionxthexpatientxinxhigh-Fowler'sxpositionxandxreassessxbreathxsounds.x-
xcorrectxanswerx ✅ANS:xB
Thexpatient'sxhistoryxandxclinicalxmanifestationsxsuggestxairwayxedemaxandxthexhealthxcarexproviderxsh
ouldxbexnotifiedximmediately,xsoxthatxintubationxcanxbexdonexrapidly.xPlacingxthexpatientxinxaxmorexupr
ightxpositionxorxhavingxthexpatientxcoughxwillxnotxaddressxthexproblemxofxairwayxedema.xContinuingxtox
monitorxisxinappropriatexbecauseximmediatexactionxshouldxoccur
AxpatientxwithxseverexburnsxhasxcrystalloidxfluidxreplacementxorderedxusingxthexParklandxformula.xThexi
nitialxvolumexofxfluidxtoxbexadministeredxinxthexfirstx24xhoursxisx30,000xmL.xThexinitialxratexofxadministr
ationxisx1875xmL/hr.xAfterxthexfirstx8xhours,xwhatxratexshouldxthexnursexinfusexthexIVxfluids?
a.x350xmL/hour
b.x523xmL/hour
c.x938xmL/hour
d.x1250xmL/hourx-xcorrectxanswerx ✅ANS:xC
HalfxofxthexfluidxreplacementxusingxthexParklandxformulaxisxadministeredxinxthexfirstx8xhoursxandxthexot
herxhalfxoverxthexnextx16xhours.xInxthisxcase,xthexpatientxshouldxreceivexhalfxofxthexinitialxrate,xorx938x
mL/hr.
Duringxthexemergentxphasexofxburnxcare,xwhichxassessmentxwillxbexmostxusefulxinxdeterminingxwhethe
rxthexpatientxisxreceivingxadequatexfluidxinfusion?
a.xCheckxskinxturgor.
b.xMonitorxdailyxweight.
c.xAssessxmucousxmembranes.
d.xMeasurexhourlyxurinexoutput.x-xcorrectxanswerx ✅ANS:xD
Whenxfluidxintakexisxadequate,xthexurinexoutputxwillxbexatxleastx0.5xtox1xmL/kg/hour.xThexpatient'sxwei
ghtxisxnotxusefulxinxthisxsituationxbecausexofxthexeffectsxofxthirdxspacingxandxevaporativexfluidxloss.xMuc
ousxmembranexassessmentxandxskinxturgorxalsoxmayxbexused,xbutxtheyxarexnotxasxadequatexinxdetermi
ningxthatxfluidxinfusionsxarexmaintainingxadequatexperfusion.
Axpatientxhasxjustxbeenxadmittedxwithxax40%xtotalxbodyxsurfacexareax(TBSA)xburnxinjury.xToxmaintainxa
dequatexnutrition,xthexnursexshouldxplanxtoxtakexwhichxaction?
,a.xInsertxaxfeedingxtubexandxinitiatexenteralxfeedings.
b.xInfusextotalxparenteralxnutritionxviaxaxcentralxcatheter.
c.xEncouragexanxoralxintakexofxatxleastx5000xkcalxperxday.
d.xAdministerxmultiplexvitaminsxandxmineralsxinxthexIVxsolution.x-xcorrectxanswerx ✅ANS:xA
Enteralxfeedingsxcanxusuallyxbexinitiatedxduringxthexemergentxphasexatxlowxratesxandxincreasedxoverx24
xtox48xhoursxtoxthexgoalxrate.xDuringxthexemergentxphase,xthexpatientxwillxbexunablextoxeatxenoughxcal
oriesxtoxmeetxnutritionalxneedsxandxmayxhavexaxparalyticxileusxthatxpreventsxadequatexnutrientxabsorpt
ion.xVitaminsxandxmineralsxmayxbexadministeredxduringxthexemergentxphase,xbutxthesexwillxnotxassistxi
nxmeetingxthexpatient'sxcaloricxneeds.xParenteralxnutritionxincreasesxthexinfectionxrisk,xdoesxnotxhelpxpr
eservexgastrointestinalxfunction,xandxisxnotxroutinelyxusedxinxburnxpatients.
Whilexthexpatient'sxfull-
thicknessxburnxwoundsxtoxthexfacexarexexposed,xwhatxisxthexbestxnursingxactionxtoxpreventxcrossxconta
mination?
a.xUsexsterilexglovesxwhenxremovingxoldxdressings.
b.xWearxgowns,xcaps,xmasks,xandxglovesxduringxallxcarexofxthexpatient.
c.xAdministerxIVxantibioticsxtoxpreventxbacterialxcolonizationxofxwounds.
d.xTurnxthexroomxtemperaturexupxtoxatxleastx70°xFx(20°xC)xduringxdressingxchanges.x-
xcorrectxanswerx ✅ANS:xB
Usexofxgowns,xcaps,xmasks,xandxglovesxduringxallxpatientxcarexwillxdecreasexthexpossibilityxofxwoundxco
ntaminationxforxaxpatientxwhosexburnsxarexnotxcovered.xWhenxremovingxcontaminatedxdressingsxandx
washingxthexdirtyxwound,xusexnonsterile,xdisposablexgloves.xThexroomxtemperaturexshouldxbexkeptxatxa
pproximatelyx85°xFxforxpatientsxwithxopenxburnxwoundsxtoxpreventxshivering.xSystemicxantibioticsxarexn
otxwellxabsorbedxintoxdeepxburnsxbecausexofxthexlackxofxcirculation.
Axnursexisxcaringxforxaxpatientxwhoxhasxburnsxofxthexears,xhead,xneck,xandxrightxarmxandxhand.xThexnur
sexshouldxplacexthexpatientxinxwhichxposition?
a.xPlacexthexrightxarmxandxhandxflexedxinxaxpositionxofxcomfort.
b.xElevatexthexrightxarmxandxhandxonxpillowsxandxextendxthexfingers.
c.xAssistxthexpatientxtoxaxsupinexpositionxwithxaxsmallxpillowxunderxthexhead.
d.xPositionxthexpatientxinxaxside-lyingxpositionxwithxrolledxtowelxunderxthexneck.x-
xcorrectxanswerx ✅ANS:xB
Thexrightxhandxandxarmxshouldxbexelevatedxtoxreducexswellingxandxthexfingersxextendedxtoxavoidxflexio
nxcontracturesx(evenxthoughxthisxpositionxmayxnotxbexcomfortablexforxthexpatient).xThexpatientxwithxbu
, rnsxofxthexearsxshouldxnotxusexaxpillowxforxthexheadxbecausexthisxwillxputxpressurexonxthexears,xandxthe
xpillowxmayxstickxtoxthexears.xPatientsxwithxneckxburnsxshouldxnotxusexaxpillowxbecausexthexheadxshoul
dxbexmaintainedxinxanxextendedxpositionxinxorderxtoxavoidxcontractures.
Axpatientxwithxcircumferentialxburnsxofxbothxlegsxdevelopsxaxdecreasexinxdorsalisxpedisxpulsexstrengthxa
ndxnumbnessxinxthextoes.xWhichxactionxshouldxthexnursextake?
a.xNotifyxthexhealthxcarexprovider.
b.xMonitorxthexpulsesxeveryx2xhours.
c.xElevatexbothxlegsxabovexheartxlevelxwithxpillows.
d.xEncouragexthexpatientxtoxflexxandxextendxthextoesxonxbothxfeet.x-xcorrectxanswerx ✅ANS:xA
Thexdecreasexinxpulsexinxaxpatientxwithxcircumferentialxburnsxindicatesxdecreasedxcirculationxtoxthexleg
sxandxthexneedxforxanxescharotomy.xMonitoringxthexpulsesxisxnotxanxadequatexresponsextoxthexdecreas
exinxcirculation.xElevatingxthexlegsxorxincreasingxtoexmovementxwillxnotximprovexthexpatient'sxcirculatio
n
Esomeprazolex(Nexium)xisxprescribedxforxaxpatientxwhoxincurredxextensivexburnxinjuriesx5xdaysxago.xW
hichxnursingxassessmentxwouldxbestxevaluatexthexeffectivenessxofxthexmedication?
a.xBowelxsounds
b.xStoolxfrequency
c.xAbdominalxdistention
d.xStoolsxforxoccultxbloodx-xcorrectxanswerx ✅ANS:xD
H2xblockersxandxprotonxpumpxinhibitorsxarexgivenxtoxpreventxCurling'sxulcerxinxthexpatientxwhoxhasxsuff
eredxburnxinjuries.xProtonxpumpxinhibitorsxusuallyxdoxnotxaffectxbowelxsounds,xstoolxfrequency,xorxapp
etite
Thexnursexisxreviewingxthexmedicationxadministrationxrecordx(MAR)xonxaxpatientxwithxpartial-
thicknessxburns.xWhichxmedicationxisxbestxforxthexnursextoxadministerxbeforexscheduledxwoundxdebrid
ement?
a.xKetorolacx(Toradol)
b.xLorazepamx(Ativan)
c.xGabapentinx(Neurontin)
d.xHydromorphonex(Dilaudid)x-xcorrectxanswerx ✅ANS:xD
Chapter 25 Burns, Exam 3 Review & Nursing Exam Prep
Whenxassessingxaxpatientxwhoxspilledxhotxoilxonxthexrightxlegxandxfoot,xthexnursexnotesxthatxthexskinxisx
dry,xpale,xhardxskin.xThexpatientxstatesxthatxthexburnxisxnotxpainful.xWhatxtermxwouldxthexnursexusextox
documentxthexburnxdepth?
a.xFirst-degreexskinxdestruction
b.xFull-thicknessxskinxdestruction
c.xDeepxpartial-thicknessxskinxdestruction
d.xSuperficialxpartial-thicknessxskinxdestructionx-xcorrectxanswerx ✅ANS:xB
Withxfull-
thicknessxskinxdestruction,xthexappearancexisxpalexandxdryxorxleatheryxandxthexareaxisxpainlessxbecausex
ofxthexassociatedxnervexdestruction.xErythema,xswelling,xandxblistersxpointxtoxaxdeepxpartial-
thicknessxburn.xWithxsuperficialxpartial-
thicknessxburns,xthexareaxisxred,xbutxnoxblistersxarexpresent.xFirst-
degreexburnsxexhibitxerythema,xblanching,xandxpain
Onxadmissionxtoxthexburnxunit,xaxpatientxwithxanxapproximatex25%xtotalxbodyxsurfacexareax(TBSA)xburn
xhasxthexfollowingxinitialxlaboratoryxresults:xHctx58%,xHgbx18.2xmg/dLx(172xg/L),xserumxK+x4.9xmEq/Lx(4.
8xmmol/L),xandxserumxNa+x135xmEq/Lx(135xmmol/L).xWhichxactionxwillxthexnursexanticipatextakingxnow
?
a.xMonitorxurinexoutputxeveryx4xhours.
b.xContinuextoxmonitorxthexlaboratoryxresults.
c.xIncreasexthexratexofxthexorderedxIVxsolution.
d.xTypexandxcrossmatchxforxaxbloodxtransfusion.x-xcorrectxanswerx ✅ANS:xC
Thexpatient'sxlaboratoryxdataxshowxhemoconcentration,xwhichxmayxleadxtoxaxdecreasexinxbloodxflowxto
xthexmicrocirculationxunlessxfluidxintakexisxincreased.xBecausexthexhematocritxandxhemoglobinxarexelev
ated,xaxtransfusionxisxinappropriate,xalthoughxtransfusionsxmayxbexneededxafterxthexemergentxphasexo
ncexthexpatient'sxfluidxbalancexhasxbeenxrestored.xOnxadmissionxtoxaxburnxunit,xthexurinexoutputxwould
xbexmonitoredxmorexoftenxthanxeveryx4xhours;xlikelyxevery1xhour.
Axpatientxisxadmittedxtoxthexburnxunitxwithxburnsxtoxthexhead,xface,xandxhands.xInitially,xwheezesxarexh
eard,xbutxanxhourxlater,xthexlungxsoundsxarexdecreasedxandxnoxwheezesxarexaudible.xWhatxisxthexbestxa
ctionxforxthexnursextoxtake?
a.xEncouragexthexpatientxtoxcoughxandxauscultatexthexlungsxagain.
,b.xNotifyxthexhealthxcarexproviderxandxpreparexforxendotrachealxintubation.
c.xDocumentxthexresultsxandxcontinuextoxmonitorxthexpatient'sxrespiratoryxrate.
d.xRepositionxthexpatientxinxhigh-Fowler'sxpositionxandxreassessxbreathxsounds.x-
xcorrectxanswerx ✅ANS:xB
Thexpatient'sxhistoryxandxclinicalxmanifestationsxsuggestxairwayxedemaxandxthexhealthxcarexproviderxsh
ouldxbexnotifiedximmediately,xsoxthatxintubationxcanxbexdonexrapidly.xPlacingxthexpatientxinxaxmorexupr
ightxpositionxorxhavingxthexpatientxcoughxwillxnotxaddressxthexproblemxofxairwayxedema.xContinuingxtox
monitorxisxinappropriatexbecauseximmediatexactionxshouldxoccur
AxpatientxwithxseverexburnsxhasxcrystalloidxfluidxreplacementxorderedxusingxthexParklandxformula.xThexi
nitialxvolumexofxfluidxtoxbexadministeredxinxthexfirstx24xhoursxisx30,000xmL.xThexinitialxratexofxadministr
ationxisx1875xmL/hr.xAfterxthexfirstx8xhours,xwhatxratexshouldxthexnursexinfusexthexIVxfluids?
a.x350xmL/hour
b.x523xmL/hour
c.x938xmL/hour
d.x1250xmL/hourx-xcorrectxanswerx ✅ANS:xC
HalfxofxthexfluidxreplacementxusingxthexParklandxformulaxisxadministeredxinxthexfirstx8xhoursxandxthexot
herxhalfxoverxthexnextx16xhours.xInxthisxcase,xthexpatientxshouldxreceivexhalfxofxthexinitialxrate,xorx938x
mL/hr.
Duringxthexemergentxphasexofxburnxcare,xwhichxassessmentxwillxbexmostxusefulxinxdeterminingxwhethe
rxthexpatientxisxreceivingxadequatexfluidxinfusion?
a.xCheckxskinxturgor.
b.xMonitorxdailyxweight.
c.xAssessxmucousxmembranes.
d.xMeasurexhourlyxurinexoutput.x-xcorrectxanswerx ✅ANS:xD
Whenxfluidxintakexisxadequate,xthexurinexoutputxwillxbexatxleastx0.5xtox1xmL/kg/hour.xThexpatient'sxwei
ghtxisxnotxusefulxinxthisxsituationxbecausexofxthexeffectsxofxthirdxspacingxandxevaporativexfluidxloss.xMuc
ousxmembranexassessmentxandxskinxturgorxalsoxmayxbexused,xbutxtheyxarexnotxasxadequatexinxdetermi
ningxthatxfluidxinfusionsxarexmaintainingxadequatexperfusion.
Axpatientxhasxjustxbeenxadmittedxwithxax40%xtotalxbodyxsurfacexareax(TBSA)xburnxinjury.xToxmaintainxa
dequatexnutrition,xthexnursexshouldxplanxtoxtakexwhichxaction?
,a.xInsertxaxfeedingxtubexandxinitiatexenteralxfeedings.
b.xInfusextotalxparenteralxnutritionxviaxaxcentralxcatheter.
c.xEncouragexanxoralxintakexofxatxleastx5000xkcalxperxday.
d.xAdministerxmultiplexvitaminsxandxmineralsxinxthexIVxsolution.x-xcorrectxanswerx ✅ANS:xA
Enteralxfeedingsxcanxusuallyxbexinitiatedxduringxthexemergentxphasexatxlowxratesxandxincreasedxoverx24
xtox48xhoursxtoxthexgoalxrate.xDuringxthexemergentxphase,xthexpatientxwillxbexunablextoxeatxenoughxcal
oriesxtoxmeetxnutritionalxneedsxandxmayxhavexaxparalyticxileusxthatxpreventsxadequatexnutrientxabsorpt
ion.xVitaminsxandxmineralsxmayxbexadministeredxduringxthexemergentxphase,xbutxthesexwillxnotxassistxi
nxmeetingxthexpatient'sxcaloricxneeds.xParenteralxnutritionxincreasesxthexinfectionxrisk,xdoesxnotxhelpxpr
eservexgastrointestinalxfunction,xandxisxnotxroutinelyxusedxinxburnxpatients.
Whilexthexpatient'sxfull-
thicknessxburnxwoundsxtoxthexfacexarexexposed,xwhatxisxthexbestxnursingxactionxtoxpreventxcrossxconta
mination?
a.xUsexsterilexglovesxwhenxremovingxoldxdressings.
b.xWearxgowns,xcaps,xmasks,xandxglovesxduringxallxcarexofxthexpatient.
c.xAdministerxIVxantibioticsxtoxpreventxbacterialxcolonizationxofxwounds.
d.xTurnxthexroomxtemperaturexupxtoxatxleastx70°xFx(20°xC)xduringxdressingxchanges.x-
xcorrectxanswerx ✅ANS:xB
Usexofxgowns,xcaps,xmasks,xandxglovesxduringxallxpatientxcarexwillxdecreasexthexpossibilityxofxwoundxco
ntaminationxforxaxpatientxwhosexburnsxarexnotxcovered.xWhenxremovingxcontaminatedxdressingsxandx
washingxthexdirtyxwound,xusexnonsterile,xdisposablexgloves.xThexroomxtemperaturexshouldxbexkeptxatxa
pproximatelyx85°xFxforxpatientsxwithxopenxburnxwoundsxtoxpreventxshivering.xSystemicxantibioticsxarexn
otxwellxabsorbedxintoxdeepxburnsxbecausexofxthexlackxofxcirculation.
Axnursexisxcaringxforxaxpatientxwhoxhasxburnsxofxthexears,xhead,xneck,xandxrightxarmxandxhand.xThexnur
sexshouldxplacexthexpatientxinxwhichxposition?
a.xPlacexthexrightxarmxandxhandxflexedxinxaxpositionxofxcomfort.
b.xElevatexthexrightxarmxandxhandxonxpillowsxandxextendxthexfingers.
c.xAssistxthexpatientxtoxaxsupinexpositionxwithxaxsmallxpillowxunderxthexhead.
d.xPositionxthexpatientxinxaxside-lyingxpositionxwithxrolledxtowelxunderxthexneck.x-
xcorrectxanswerx ✅ANS:xB
Thexrightxhandxandxarmxshouldxbexelevatedxtoxreducexswellingxandxthexfingersxextendedxtoxavoidxflexio
nxcontracturesx(evenxthoughxthisxpositionxmayxnotxbexcomfortablexforxthexpatient).xThexpatientxwithxbu
, rnsxofxthexearsxshouldxnotxusexaxpillowxforxthexheadxbecausexthisxwillxputxpressurexonxthexears,xandxthe
xpillowxmayxstickxtoxthexears.xPatientsxwithxneckxburnsxshouldxnotxusexaxpillowxbecausexthexheadxshoul
dxbexmaintainedxinxanxextendedxpositionxinxorderxtoxavoidxcontractures.
Axpatientxwithxcircumferentialxburnsxofxbothxlegsxdevelopsxaxdecreasexinxdorsalisxpedisxpulsexstrengthxa
ndxnumbnessxinxthextoes.xWhichxactionxshouldxthexnursextake?
a.xNotifyxthexhealthxcarexprovider.
b.xMonitorxthexpulsesxeveryx2xhours.
c.xElevatexbothxlegsxabovexheartxlevelxwithxpillows.
d.xEncouragexthexpatientxtoxflexxandxextendxthextoesxonxbothxfeet.x-xcorrectxanswerx ✅ANS:xA
Thexdecreasexinxpulsexinxaxpatientxwithxcircumferentialxburnsxindicatesxdecreasedxcirculationxtoxthexleg
sxandxthexneedxforxanxescharotomy.xMonitoringxthexpulsesxisxnotxanxadequatexresponsextoxthexdecreas
exinxcirculation.xElevatingxthexlegsxorxincreasingxtoexmovementxwillxnotximprovexthexpatient'sxcirculatio
n
Esomeprazolex(Nexium)xisxprescribedxforxaxpatientxwhoxincurredxextensivexburnxinjuriesx5xdaysxago.xW
hichxnursingxassessmentxwouldxbestxevaluatexthexeffectivenessxofxthexmedication?
a.xBowelxsounds
b.xStoolxfrequency
c.xAbdominalxdistention
d.xStoolsxforxoccultxbloodx-xcorrectxanswerx ✅ANS:xD
H2xblockersxandxprotonxpumpxinhibitorsxarexgivenxtoxpreventxCurling'sxulcerxinxthexpatientxwhoxhasxsuff
eredxburnxinjuries.xProtonxpumpxinhibitorsxusuallyxdoxnotxaffectxbowelxsounds,xstoolxfrequency,xorxapp
etite
Thexnursexisxreviewingxthexmedicationxadministrationxrecordx(MAR)xonxaxpatientxwithxpartial-
thicknessxburns.xWhichxmedicationxisxbestxforxthexnursextoxadministerxbeforexscheduledxwoundxdebrid
ement?
a.xKetorolacx(Toradol)
b.xLorazepamx(Ativan)
c.xGabapentinx(Neurontin)
d.xHydromorphonex(Dilaudid)x-xcorrectxanswerx ✅ANS:xD
