Grade A+ Burns NCLEX style questions with rationales 2025
When assessing a patient with a partial-thickness burn, the nurse
would expect to find (SATA): Correct answers: a, d, e
a. blisters Rationale: The appearance of partial-thickness (deep) burns may
b. exposed fascia include fluid-filled vesicles (blisters) that are red, shiny, or wet (if
c. exposed muscles vesicles have ruptured). Patients may have severe pain caused by
d. intact nerve endings exposure of nerve endings and may have mild to moderate edema.
e. red, shiny, wet appearance
Correct answers: a, c, d
Pain management for the burn patient is most effective when
(SATA):
Rationale: The use of a pain rating tool assists the nurse in the
assessment, monitoring, and evaluation of the pain management
a. a pain rating tool is used to monitor the patient's level of pain
plan. The more control the patient has in managing the pain, the
b. painful dressing changes are delayed until the patient's pain is
more successful the chosen strategies are. A selected variety of
completely relieved
medications offer better pain relief for patients with burns, whose
c. the patient is informed about and has some control over the
pain can be both continuous and treatment related over varying
management of the pain
periods of time. It is not realistic to promise a patient that pain will
d. a multi-modal approach is used (e.g., sustained-release and
be completely eliminated. It is not realistic to suggest that pain
short-acting opioids, NSAIDS, adjuvant analgesics).
e. will be managed (during any phase of burn care) with nonphar-
non-pharmacological therapies (e.g., music therapy, distraction)
macologic pain management. Such management is meant to be
replace opioids in the rehabilitation phase of a burn injury
adjuvant and individualized.
The nurse is caring for a patient with superficial partial-thickness
burns of the face sustained within the last 12 hours. Upon assess-
b.
ment the nurse would expect to find which manifestation?
The clinical appearance of superficial partial-thickness burns in-
a. blisters
cludes erythema, blanching with pressure, and pain and minimal
b. reddening of the skin
swelling with no vesicles or blistering during the first 24 hours.
c. destruction of all skin layers
d. damage to sebaceous glands
a, c, d, e
The nurse is planning care for a patient with partial- and full-thick-
ness skin destruction related to burn injury of the lower extremi- An escharotomy (a scalpel incision through full-thickness eschar)
ties. Which interventions should the nurse expect to include in this
is frequently required to restore circulation to compromised ex-
patient's care ()? (select all that apply)?
tremities. Daily cleansing and debridement as well as application
of an antimicrobial ointment are expected interventions used to
a. escharotomy
minimize infection and enhance wound healing. Pain control is es-
b. administration of diuretics
sential in the care of a patient with a burn injury. With full-thickness
c. IV and oral pain medications
burns, myoglobin and hemoglobin released into the bloodstream
d. daily cleansing and debridement
can occlude renal tubules. Adequate fluid replacement is used to
e. application of topical antimicrobial agent
prevent this occlusion.
The nurse is caring for a patient with partial- and full-thickness
d.
burns to 65% of the body. When planning nutritional interventions
for this patient, what dietary choices should the nurse implement?
A hypermetabolic state occurs proportional to the size of the
burn area. Massive catabolism can occur and is characterized
a. full liquids only
by protein breakdown and increased gluconeogenesis. Caloric
b. whatever the patient requests
needs are often in the 5000-kcal range. Failure to supply adequate
c. high-protein and low sodium foods
calories and protein leads to malnutrition and delayed healing.
d. high calorie and high protein foods
c.
When caring for a patient with an electrical burn injury, which order An infusion rate of 25 mL/hr is not sufficient to maintain adequate
from the health care provider should the nurse question? urine output in prevention and treatment of ATN.
Electrical injury puts the patient at risk for myoglobinuria, which
a. mannitol 75 gm IV can lead to acute renal tubular necrosis (ATN). Treatment consists
b. urine for myoglobulin of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient
c. LR at 25 mL/h to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be
d. sodium bicarbonate 24 mEq q.4h used to maintain urine output. Sodium bicarbonate may be given
to alkalinize the urine. The urine would also be monitored for the
presence of myoglobin.
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When assessing a patient with a partial-thickness burn, the nurse
would expect to find (SATA): Correct answers: a, d, e
a. blisters Rationale: The appearance of partial-thickness (deep) burns may
b. exposed fascia include fluid-filled vesicles (blisters) that are red, shiny, or wet (if
c. exposed muscles vesicles have ruptured). Patients may have severe pain caused by
d. intact nerve endings exposure of nerve endings and may have mild to moderate edema.
e. red, shiny, wet appearance
Correct answers: a, c, d
Pain management for the burn patient is most effective when
(SATA):
Rationale: The use of a pain rating tool assists the nurse in the
assessment, monitoring, and evaluation of the pain management
a. a pain rating tool is used to monitor the patient's level of pain
plan. The more control the patient has in managing the pain, the
b. painful dressing changes are delayed until the patient's pain is
more successful the chosen strategies are. A selected variety of
completely relieved
medications offer better pain relief for patients with burns, whose
c. the patient is informed about and has some control over the
pain can be both continuous and treatment related over varying
management of the pain
periods of time. It is not realistic to promise a patient that pain will
d. a multi-modal approach is used (e.g., sustained-release and
be completely eliminated. It is not realistic to suggest that pain
short-acting opioids, NSAIDS, adjuvant analgesics).
e. will be managed (during any phase of burn care) with nonphar-
non-pharmacological therapies (e.g., music therapy, distraction)
macologic pain management. Such management is meant to be
replace opioids in the rehabilitation phase of a burn injury
adjuvant and individualized.
The nurse is caring for a patient with superficial partial-thickness
burns of the face sustained within the last 12 hours. Upon assess-
b.
ment the nurse would expect to find which manifestation?
The clinical appearance of superficial partial-thickness burns in-
a. blisters
cludes erythema, blanching with pressure, and pain and minimal
b. reddening of the skin
swelling with no vesicles or blistering during the first 24 hours.
c. destruction of all skin layers
d. damage to sebaceous glands
a, c, d, e
The nurse is planning care for a patient with partial- and full-thick-
ness skin destruction related to burn injury of the lower extremi- An escharotomy (a scalpel incision through full-thickness eschar)
ties. Which interventions should the nurse expect to include in this
is frequently required to restore circulation to compromised ex-
patient's care ()? (select all that apply)?
tremities. Daily cleansing and debridement as well as application
of an antimicrobial ointment are expected interventions used to
a. escharotomy
minimize infection and enhance wound healing. Pain control is es-
b. administration of diuretics
sential in the care of a patient with a burn injury. With full-thickness
c. IV and oral pain medications
burns, myoglobin and hemoglobin released into the bloodstream
d. daily cleansing and debridement
can occlude renal tubules. Adequate fluid replacement is used to
e. application of topical antimicrobial agent
prevent this occlusion.
The nurse is caring for a patient with partial- and full-thickness
d.
burns to 65% of the body. When planning nutritional interventions
for this patient, what dietary choices should the nurse implement?
A hypermetabolic state occurs proportional to the size of the
burn area. Massive catabolism can occur and is characterized
a. full liquids only
by protein breakdown and increased gluconeogenesis. Caloric
b. whatever the patient requests
needs are often in the 5000-kcal range. Failure to supply adequate
c. high-protein and low sodium foods
calories and protein leads to malnutrition and delayed healing.
d. high calorie and high protein foods
c.
When caring for a patient with an electrical burn injury, which order An infusion rate of 25 mL/hr is not sufficient to maintain adequate
from the health care provider should the nurse question? urine output in prevention and treatment of ATN.
Electrical injury puts the patient at risk for myoglobinuria, which
a. mannitol 75 gm IV can lead to acute renal tubular necrosis (ATN). Treatment consists
b. urine for myoglobulin of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient
c. LR at 25 mL/h to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be
d. sodium bicarbonate 24 mEq q.4h used to maintain urine output. Sodium bicarbonate may be given
to alkalinize the urine. The urine would also be monitored for the
presence of myoglobin.
1/2
