CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless
because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-
thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-
degree burns exhibit erythema, blanching, and pain
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the
tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain,
blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema,
blanching, and redness occur with partial-thickness (superficial, first-degree) burns.
With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as
possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was
exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or
water. Covering the affected area or placing cool compresses on the area will leave the chemical in
contact with the skin. Application of an alkaline solution is not recommended.
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to
prevent cross contamination?
Which patient should the nurse assess first?
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN)
who has floated from the hospital medical unit?
Which nursing action is a priority for a patient who has suffered a burn injury while working on an
electrical power line?
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a
burn injury to the right arm and chest?
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse
give to the patient? (select all that apply)?
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse
give to the patient? Select all that apply.
When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse
assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the
findings?
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight
is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous
membrane assessment and skin turgor also may be used, but they are not as adequate in determining
that fluid infusions are maintaining adequate perfusion.
When evaluating the laboratory values of the burn-injured patient, which of the following can be
anticipated?
,CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
When caring for a patient with an electrical burn injury, which order from the health care provider
should the nurse question?
When caring for a patient with an electrical burn injury, which order from the health care provider
should the nurse question?
When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA):
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to
document the burn depth?
Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the
body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk
encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior
trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the
three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns
to cover approximately 22.5% of the total body surface area.
Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the
body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk
encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior
trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the
three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns
to cover approximately 22.5% of the total body surface area.
Using the modified Brooke formula, calculate the amount of intravenous solution that will be
administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg. - ansCorrect Answer:
2080 mL
Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound
contamination for a patient whose burns are not covered. When removing contaminated dressings and
washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at
approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are
not well absorbed into deep burns because of the lack of circulation.
To maintain a positive nitrogen balance in a major burn, the patient must:
This response acknowledges the patient's feelings and asks for more assessment data that will help in
developing an appropriate plan of care to assist the patient with the emotional response to the burn
injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the
patient is expressing.
This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a
patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this
patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because
,CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by
low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the
pH and serum potassium abnormalities.
This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to
determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as
possible, but they do not have evidence of life-threatening complications.
The willingness to use strategies to enhance appearance is an indication that the disturbed body image is
resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not
resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that
the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow
will help prevent contractures, but it does not address the problem of disturbed body image
The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is
at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV
fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate
should be less than 120. Serous exudate from the burns is expected during the emergent phase
The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion
contractures (even though this position may not be comfortable for the patient). The patient with burns
of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow
may stick to the ears. Patients with neck burns should not use a pillow because the head should be
maintained in an extended position in order to avoid contractures.
The patient's urine output indicates that the patient is entering the acute phase of the burn injury and
moving on from the emergent stage. At the end of the emergent phase, capillary permeability
normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although
this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve,
but this process requires more time. White blood cells may increase or decrease, based on the patient's
immune status and any infectious processes. The WBC count does not indicate kidney function. The
patient will likely remain in the burn unit during the acute stage of burn injury
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to
the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are
elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase
once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would
be monitored more often than every 4 hours; likely every1 hour.
The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by
rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.
The patient's history and clinical manifestations suggest airway edema and the health care provider
should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more
, CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
upright position or having the patient cough will not address the problem of airway edema. Continuing
to monitor is inappropriate because immediate action should occur
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse
include in the discharge teaching for this patient?
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse
include in the discharge teaching for this patient?
The patient in the emergent phase of a burn injury is being treated for pain. What medication should the
nurse anticipate using for this patient?
The patient 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 level of 485 mg/dL. What should be the nurse's priority
intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?
The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24
hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4
80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum
potassium level. The nurse realizes that this finding is consistent with which of the following?
The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who
experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would
the nurse expect to see?
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness
burns. Which medication is best for the nurse to administer before scheduled wound debridement?
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result
requires priority action by the nurse?
The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm. During
wound care, the nurse applies Elase to the burned areas. Which of the following types ofwound
debridement is this nurse using?
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn
injury of the lower extremities. Which interventions should the nurse expect to include in this patient's
care? (Select all that apply.)
The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the
following laboratory values is the best indicator of a need to adjust the nutritional program?
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the
last 12 hours. Upon assessment the nurse would expect to find which manifestation?
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless
because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-
thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-
degree burns exhibit erythema, blanching, and pain
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the
tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain,
blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema,
blanching, and redness occur with partial-thickness (superficial, first-degree) burns.
With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as
possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was
exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or
water. Covering the affected area or placing cool compresses on the area will leave the chemical in
contact with the skin. Application of an alkaline solution is not recommended.
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to
prevent cross contamination?
Which patient should the nurse assess first?
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN)
who has floated from the hospital medical unit?
Which nursing action is a priority for a patient who has suffered a burn injury while working on an
electrical power line?
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a
burn injury to the right arm and chest?
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse
give to the patient? (select all that apply)?
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse
give to the patient? Select all that apply.
When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse
assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the
findings?
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight
is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous
membrane assessment and skin turgor also may be used, but they are not as adequate in determining
that fluid infusions are maintaining adequate perfusion.
When evaluating the laboratory values of the burn-injured patient, which of the following can be
anticipated?
,CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
When caring for a patient with an electrical burn injury, which order from the health care provider
should the nurse question?
When caring for a patient with an electrical burn injury, which order from the health care provider
should the nurse question?
When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA):
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to
document the burn depth?
Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the
body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk
encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior
trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the
three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns
to cover approximately 22.5% of the total body surface area.
Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the
body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk
encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior
trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the
three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns
to cover approximately 22.5% of the total body surface area.
Using the modified Brooke formula, calculate the amount of intravenous solution that will be
administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg. - ansCorrect Answer:
2080 mL
Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound
contamination for a patient whose burns are not covered. When removing contaminated dressings and
washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at
approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are
not well absorbed into deep burns because of the lack of circulation.
To maintain a positive nitrogen balance in a major burn, the patient must:
This response acknowledges the patient's feelings and asks for more assessment data that will help in
developing an appropriate plan of care to assist the patient with the emotional response to the burn
injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the
patient is expressing.
This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a
patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this
patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because
,CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by
low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the
pH and serum potassium abnormalities.
This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to
determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as
possible, but they do not have evidence of life-threatening complications.
The willingness to use strategies to enhance appearance is an indication that the disturbed body image is
resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not
resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that
the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow
will help prevent contractures, but it does not address the problem of disturbed body image
The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is
at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV
fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate
should be less than 120. Serous exudate from the burns is expected during the emergent phase
The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion
contractures (even though this position may not be comfortable for the patient). The patient with burns
of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow
may stick to the ears. Patients with neck burns should not use a pillow because the head should be
maintained in an extended position in order to avoid contractures.
The patient's urine output indicates that the patient is entering the acute phase of the burn injury and
moving on from the emergent stage. At the end of the emergent phase, capillary permeability
normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although
this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve,
but this process requires more time. White blood cells may increase or decrease, based on the patient's
immune status and any infectious processes. The WBC count does not indicate kidney function. The
patient will likely remain in the burn unit during the acute stage of burn injury
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to
the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are
elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase
once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would
be monitored more often than every 4 hours; likely every1 hour.
The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by
rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.
The patient's history and clinical manifestations suggest airway edema and the health care provider
should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more
, CHAPTER 25 NCLEX STYLE PRACTICE QUESTIONS
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
upright position or having the patient cough will not address the problem of airway edema. Continuing
to monitor is inappropriate because immediate action should occur
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse
include in the discharge teaching for this patient?
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse
include in the discharge teaching for this patient?
The patient in the emergent phase of a burn injury is being treated for pain. What medication should the
nurse anticipate using for this patient?
The patient 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 level of 485 mg/dL. What should be the nurse's priority
intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?
The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24
hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4
80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum
potassium level. The nurse realizes that this finding is consistent with which of the following?
The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who
experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would
the nurse expect to see?
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness
burns. Which medication is best for the nurse to administer before scheduled wound debridement?
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result
requires priority action by the nurse?
The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm. During
wound care, the nurse applies Elase to the burned areas. Which of the following types ofwound
debridement is this nurse using?
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn
injury of the lower extremities. Which interventions should the nurse expect to include in this patient's
care? (Select all that apply.)
The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the
following laboratory values is the best indicator of a need to adjust the nutritional program?
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the
last 12 hours. Upon assessment the nurse would expect to find which manifestation?
