NUR 213 NCLEX Questions
1. A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious
irrigation to the site was performed for 1 hour. On admission tothe hospital emergency
department, the nurse assesses the burn site. Whichfindings would indicate that the chemical
burn process is continuing?
1.
Eschar
2.
Intact blisters
3.
Liquefaction necrosis
4.
Cherry-red, firm tissue: 3.Liquefaction necrosis
Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a
soapy coagulum. Thick, leathery eschar forms with exposure to acidsor heat. Intact blisters
indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of
thermal injury.
2. The nurse is caring for a client who was admitted to the burn unit after sus-taining a burn
injury covering 30% of the body. What is the most appropriatetime frame for the emergent
phase?
1.
The entire period of time during which rehabilitation occurs
2.
The period from the time the client is stable to the time when all burns arecovered with skin
3.
The period from the time the burn was incurred to the time when the client isadmitted to the
hospital
4.
The period from the time the burn was incurred to the time when the client isconsidered
, physiologically stable: 4.
The period from the time the burn was incurred to the time when the client is considered
physiologically stable
The emergent phase of burn care generally extends from the time the burn injury isincurred
until the time when the client is considered physiologically stable. The acutephase lasts until all
full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5
years for an adult and includes reintegration into society.
3. The nurse is caring for a client with full-thickness circumferential burns of the entire trunk
of the body. Which finding suggests that an escharotomy maybe necessary?
1.
Pallor of all extremities
2.
Pulse oximetry reading of 93%
3.
Peripheral pulses are diminished
4.
High pressure alarm keeps sounding on the ventilator: 4.High pressure alarm keeps sounding
on the ventilator
A client with a circumferential burn of the entire trunk likely will be on a ventilator because
of the potential for breathing to be affected by this injury. The high pressurealarm will sound on
the ventilator when there is any kind of obstruction. If the chestcannot expand due to
restriction by eschar and increasing edema, this results in obstruction.
4. The nurse is planning care for a client who suffered a burn injury and hasa negative self-
image related to keloid formation at the burn site. The keloid formation is indicative of which
condition?
1.
Nerve damage
2.
Hypertrophy of collagen fibers
3.
Compromised circulation at the burn site
4.
1. A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious
irrigation to the site was performed for 1 hour. On admission tothe hospital emergency
department, the nurse assesses the burn site. Whichfindings would indicate that the chemical
burn process is continuing?
1.
Eschar
2.
Intact blisters
3.
Liquefaction necrosis
4.
Cherry-red, firm tissue: 3.Liquefaction necrosis
Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a
soapy coagulum. Thick, leathery eschar forms with exposure to acidsor heat. Intact blisters
indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of
thermal injury.
2. The nurse is caring for a client who was admitted to the burn unit after sus-taining a burn
injury covering 30% of the body. What is the most appropriatetime frame for the emergent
phase?
1.
The entire period of time during which rehabilitation occurs
2.
The period from the time the client is stable to the time when all burns arecovered with skin
3.
The period from the time the burn was incurred to the time when the client isadmitted to the
hospital
4.
The period from the time the burn was incurred to the time when the client isconsidered
, physiologically stable: 4.
The period from the time the burn was incurred to the time when the client is considered
physiologically stable
The emergent phase of burn care generally extends from the time the burn injury isincurred
until the time when the client is considered physiologically stable. The acutephase lasts until all
full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5
years for an adult and includes reintegration into society.
3. The nurse is caring for a client with full-thickness circumferential burns of the entire trunk
of the body. Which finding suggests that an escharotomy maybe necessary?
1.
Pallor of all extremities
2.
Pulse oximetry reading of 93%
3.
Peripheral pulses are diminished
4.
High pressure alarm keeps sounding on the ventilator: 4.High pressure alarm keeps sounding
on the ventilator
A client with a circumferential burn of the entire trunk likely will be on a ventilator because
of the potential for breathing to be affected by this injury. The high pressurealarm will sound on
the ventilator when there is any kind of obstruction. If the chestcannot expand due to
restriction by eschar and increasing edema, this results in obstruction.
4. The nurse is planning care for a client who suffered a burn injury and hasa negative self-
image related to keloid formation at the burn site. The keloid formation is indicative of which
condition?
1.
Nerve damage
2.
Hypertrophy of collagen fibers
3.
Compromised circulation at the burn site
4.
