Burns NCLEX Practice/Real NCLEX-Based Questions
and Approved Answers/Guaranteed Perfect score
100% Accuracy/Latest Update 2025
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase.
The patient tells the nurse, ìI can't wait to have surgery to reconstruct my face so I look normal
again.î What would be the nurse's best response?
A) ìThat's something that you and your doctor will likely talk about after your scars mature.î
B) ìThat is something for you to talk to your doctor about because it's not a nursing
responsibility.î
C) ìI know this is really important to you, but you have to realize that no one can make you look
like you used to.î
D) ìUnfortunately, it's likely that you will have most of these scars for the rest of your life.î -
Correct Answers-Ans: A
Feedback:
Burn reconstruction is a treatment option after all scars have matured and is discussed within
the first few years after injury. Even though this is not a nursing responsibility, the nurse should
still respond appropriately to the patient's query. It is true that the patient will not realistically
look like he or she used to, but this does not instill hope.
A child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated
for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the
most appropriate nursing action?
a. give a small glass of clear liquid
b. give a small glass of a full liquid
c. keep the child NPO
d. order a pediatric meal tray with extra liquids - Correct Answers-c. Until a complete
assessment and treatment plan are initiated, the child should be kept NPO. A complication of
major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be
provided.
,A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment
by the nurse requires immediate action?
a. coughing and wheezing
b. bright red skin with small blister on the burn sites
c. thirst
d. singed hair - Correct Answers-a. coughing and wheezing may indicate that the child has
inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this
situation.
A client is admitted to a burn intensive care unit with extensive full thickness burns. What
should be the nurse's initial concern?
a. fluid status
b. risk for infection
c. body image
d. level of pain - Correct Answers-a. in early burn care, the client's greatest need has to do
with fluid resuscitation because of large volume fluid loss through the damaged skin.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago.
The nursing assessment reveals a blood pressure of 90/50, a pulse of 110, and urine output of
20 mL over the past hour. The nurse reports the findings to the physician and anticipates which
of the following prescriptions?
a. transfusing 1 unit of packed red blood cells
b. administering a diuretic to increase urine output
c. increasing the amount of IV lactated Ringers solution administered per hour
d. changing the IV lactated Ringer's solution to one that contains dextrose in water. - Correct
Answers-c. fluid management during the first 24 hours following a burn injury generally includes
the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine
output should be at least 30mL/hr. The client's urine output is indicative of insufficient fluid
resuscitation, which places the client at risk for inadequate perfusion of the brain, heart,
kidneys, and other body organs. Therefore, should expect ↑ of LR's.
A client with burn injury asks the nurse what the term full thickness means. The nurse should
respond that burns classified as full thickness involve tissue destruction down to which level?
,a. epidermis
b. dermis
c. subcutaneous tissue
d. internal organs - Correct Answers-c. A full thickness burn involves all skin layers, including
the epidermis and dermis, and may extend into the subcutaneous tissue and fat.
A client's burn is infected and mafenide (Sulfamylon) is prescribed. The nurse's knowledge
about this medication would indicate that which organism is involved?
a. pseudomonas aeruginosa
b. tubercle bacillus
c. Methicillin resistant staphylococcus aureus (MRSA)
d. Candida albicans - Correct Answers-a. Mafenide is useful in treatment of partial and full
thickness burns to prevent septicemia caused by organisms suche as pseudomonas aeruginosa.
A female pt in the acute phase of burn care has electrical burns on the left side of her body,
type 2 diabetes mellitus, and a serum glucose of 485 mg/dL. What is the nurse's priority for
preventing a life threatening complication of hyperglycemia for the burn patient?
a. replace the blood lost
b. maintain a neutral pH
c. Maintain fluid balance
d. Replace serum potassium - Correct Answers-c. this pt is most likely experiencing
hyperglycemic hyperosmolar nonketotic syndrome (HHNKS) which dehydrates a patient rapidly.
This increases the pt's risk for hypovolemia and hypotension.
A home care nurse is performing a visit to a patient's home to perform wound care following
the patient's hospital treatment for severe burns. While interacting with the patient, the nurse
should assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia - Correct Answers-Ans: B
, Feedback:
Post-traumatic stress disorder (PTSD) is the most common psychiatric disorder in burn
survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse
to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not
among the noted psychiatric and psychosocial complications of burns.
A male burn pt who was struck by lightning arrives at the emergency department with full
thickness burns to the arms and chest and with a cervical collar in place. Which assessment
finding is the nurse's priority?
a. serum K+ of 5.6 mEq/L
b. Arterial blood ph of 7.35
c. Cervical spine fracture
d. hemoglobin 18g/dL - Correct Answers-a. The pt's potassium level puts them at risk for life
threatening cardiac dysrhythmias.
A male pt suffered full thickness burns to the chest and back and the nurse notes the pressure
alarm on his mechanical ventilator is sounding every 5 minutes. What is the most relevant
assessment to prevent respiratory complications in this pt?
a. pH
b. PaCO2
c. Breath sounds
d. chest expansion - Correct Answers-d. assessing the pt's chest expansion is initially the
most important because a sever burn that includes the anterior and posterior thorax can
restrict chest expansion from eschar or scar tissue.
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital.
Which patient is most likely to have life-threatening complications?
A) A 4-year-old scald victim burned over 24% of the body
B) A 27-year-old male burned over 36% of his body in a car accident
C) A 39-year-old female patient burned over 18% of her body
D) A 60-year-old male burned over 16% of his body in a brush fire - Correct Answers-Ans: A
Feedback:
and Approved Answers/Guaranteed Perfect score
100% Accuracy/Latest Update 2025
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase.
The patient tells the nurse, ìI can't wait to have surgery to reconstruct my face so I look normal
again.î What would be the nurse's best response?
A) ìThat's something that you and your doctor will likely talk about after your scars mature.î
B) ìThat is something for you to talk to your doctor about because it's not a nursing
responsibility.î
C) ìI know this is really important to you, but you have to realize that no one can make you look
like you used to.î
D) ìUnfortunately, it's likely that you will have most of these scars for the rest of your life.î -
Correct Answers-Ans: A
Feedback:
Burn reconstruction is a treatment option after all scars have matured and is discussed within
the first few years after injury. Even though this is not a nursing responsibility, the nurse should
still respond appropriately to the patient's query. It is true that the patient will not realistically
look like he or she used to, but this does not instill hope.
A child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated
for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the
most appropriate nursing action?
a. give a small glass of clear liquid
b. give a small glass of a full liquid
c. keep the child NPO
d. order a pediatric meal tray with extra liquids - Correct Answers-c. Until a complete
assessment and treatment plan are initiated, the child should be kept NPO. A complication of
major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be
provided.
,A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment
by the nurse requires immediate action?
a. coughing and wheezing
b. bright red skin with small blister on the burn sites
c. thirst
d. singed hair - Correct Answers-a. coughing and wheezing may indicate that the child has
inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this
situation.
A client is admitted to a burn intensive care unit with extensive full thickness burns. What
should be the nurse's initial concern?
a. fluid status
b. risk for infection
c. body image
d. level of pain - Correct Answers-a. in early burn care, the client's greatest need has to do
with fluid resuscitation because of large volume fluid loss through the damaged skin.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago.
The nursing assessment reveals a blood pressure of 90/50, a pulse of 110, and urine output of
20 mL over the past hour. The nurse reports the findings to the physician and anticipates which
of the following prescriptions?
a. transfusing 1 unit of packed red blood cells
b. administering a diuretic to increase urine output
c. increasing the amount of IV lactated Ringers solution administered per hour
d. changing the IV lactated Ringer's solution to one that contains dextrose in water. - Correct
Answers-c. fluid management during the first 24 hours following a burn injury generally includes
the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine
output should be at least 30mL/hr. The client's urine output is indicative of insufficient fluid
resuscitation, which places the client at risk for inadequate perfusion of the brain, heart,
kidneys, and other body organs. Therefore, should expect ↑ of LR's.
A client with burn injury asks the nurse what the term full thickness means. The nurse should
respond that burns classified as full thickness involve tissue destruction down to which level?
,a. epidermis
b. dermis
c. subcutaneous tissue
d. internal organs - Correct Answers-c. A full thickness burn involves all skin layers, including
the epidermis and dermis, and may extend into the subcutaneous tissue and fat.
A client's burn is infected and mafenide (Sulfamylon) is prescribed. The nurse's knowledge
about this medication would indicate that which organism is involved?
a. pseudomonas aeruginosa
b. tubercle bacillus
c. Methicillin resistant staphylococcus aureus (MRSA)
d. Candida albicans - Correct Answers-a. Mafenide is useful in treatment of partial and full
thickness burns to prevent septicemia caused by organisms suche as pseudomonas aeruginosa.
A female pt in the acute phase of burn care has electrical burns on the left side of her body,
type 2 diabetes mellitus, and a serum glucose of 485 mg/dL. What is the nurse's priority for
preventing a life threatening complication of hyperglycemia for the burn patient?
a. replace the blood lost
b. maintain a neutral pH
c. Maintain fluid balance
d. Replace serum potassium - Correct Answers-c. this pt is most likely experiencing
hyperglycemic hyperosmolar nonketotic syndrome (HHNKS) which dehydrates a patient rapidly.
This increases the pt's risk for hypovolemia and hypotension.
A home care nurse is performing a visit to a patient's home to perform wound care following
the patient's hospital treatment for severe burns. While interacting with the patient, the nurse
should assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia - Correct Answers-Ans: B
, Feedback:
Post-traumatic stress disorder (PTSD) is the most common psychiatric disorder in burn
survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse
to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not
among the noted psychiatric and psychosocial complications of burns.
A male burn pt who was struck by lightning arrives at the emergency department with full
thickness burns to the arms and chest and with a cervical collar in place. Which assessment
finding is the nurse's priority?
a. serum K+ of 5.6 mEq/L
b. Arterial blood ph of 7.35
c. Cervical spine fracture
d. hemoglobin 18g/dL - Correct Answers-a. The pt's potassium level puts them at risk for life
threatening cardiac dysrhythmias.
A male pt suffered full thickness burns to the chest and back and the nurse notes the pressure
alarm on his mechanical ventilator is sounding every 5 minutes. What is the most relevant
assessment to prevent respiratory complications in this pt?
a. pH
b. PaCO2
c. Breath sounds
d. chest expansion - Correct Answers-d. assessing the pt's chest expansion is initially the
most important because a sever burn that includes the anterior and posterior thorax can
restrict chest expansion from eschar or scar tissue.
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital.
Which patient is most likely to have life-threatening complications?
A) A 4-year-old scald victim burned over 24% of the body
B) A 27-year-old male burned over 36% of his body in a car accident
C) A 39-year-old female patient burned over 18% of her body
D) A 60-year-old male burned over 16% of his body in a brush fire - Correct Answers-Ans: A
Feedback:
