Burns NCLEX Question and Burn Injury Nursing Management Exam Pack Part 2 Updated 2022

1. 1. Question The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN? o A. Administer the prescribed tetanus toxoid vaccine. o B. Assess wounds for signs of infection. o C. Encourage the client to cough and breathe deeply. o D. Wash hands on entering the client's room. Correct Answer: D. Wash hands on entering the client’s room. Infection can occur when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations. Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. • Option A: Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity. • Option B: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. • Option C: Although all the interventions listed can help reduce the risk of infection, hand washing is the most effective technique for preventing infection transmission. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn. 2. 2. Question Three days after a burn injury, the client develops a temperature of 100° F, a white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? • A. Acute phase of the injury • B. Autodigestion of collagen • C. Granulation of burned tissue • D. Wound infection Correct Answer: D. Wound infection Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies. • Option A: These symptoms will not be seen in the acute phase of the injury. Assess and document size, color, depth of wound, noting necrotic tissue and condition of the surrounding skin. • Option B: Autodigestion of collagen will not increase the body temperature or cause foul-smelling wound discharge. Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria. • Option C: Granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge. Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.