Burn NCLEX

Burn NCLEX
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1. 1. A patient is brought to the Emergency FULL THICKNESS

Department from the site of a chemical
fire. The paramedics report that the pa- **A full-thickness burn involves
tient has a burn that involves the epider- total destruction of the epider-
mis, dermis, and the muscle and bone mis and dermis and, in some
of the right arm. When you assess the cases, underlying tissue as well.
patient he verbalizes no pain in the right Wound color ranges widely from
arm and the skin appears charred. Based white to red, brown, or black. The
upon these assessment findings, what burned area is painless because
is the depth of the burn on the patient's the nerve fibers are destroyed.
right arm? The wound can appear leathery;
A) Superficial partial-thickness hair follicles and sweat glands
B) Deep partial-thickness are destroyed. Edema may also
C) Full partial-thickness be present. Full partial thickness
D) Full-thickness is not a depth of burn. Super-
ficial partial-thickness burns in-
volve the epidermis and possibly
a portion of the dermis and the
patient will experience pain that
is soothed by cooling. Deep par-
tial-thickness burns involve the
epidermis, upper dermis, and
portion of the deeper dermis and
the patient will complain of pain
and sensitivity to cold air.
2. 2. The nursing instructor is going over ACUTE

burn
injuries. The instructor tells the students **The acute or intermediate
that the nursing care priorities for a pa- phase of burn care
tient with a burn injury include wound follows the emergent/resuscita-
care, nutritional support, and preven- tive phase and begins 48 to 72
tion of complications such as infection. hours after the burn injury. Dur-
Based upon these care priorities, the in- ing this phase, attention is di-
structor is most likely discussing a pa- rected toward continued assess-
tient in what phase of burn care? ment and maintenance of respi-
A) Emergent ratory and circulatory status, flu-
B) Immediate resuscitative id and electrolyte balance, and
gastrointestinal function. Infec-
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Burn NCLEX
C) Acute tion prevention, burn wound care
D) Rehabilitation (ie, wound cleaning, topical an-
tibacterial therapy, wound dress-
ing, dressing changes, wound
debridement, and wound graft-
ing), pain management, and nu-
tritional support are priorities at
this stage and are discussed
in detail in the following sec-
tions. Priorities during the emer-
gent or immediate resuscitative
phase include first aid, preven-
tion of shock and respiratory dis-
tress, detection and treatment
of concomitant injuries, and ini-
tial wound assessment and care.
The priorities during the rehabil-
itation phase include prevention
of scars and contractures, reha-
bilitation, functional and cosmet-
ic reconstruction, and psychoso-
cial counseling.
3. 3. A patient in the emergent/resuscitative HYPERKALEMIA, HYPONA-

phase of a burn injury has had her lab TREMIA, ELEVATED HEMAT-
work drawn. Upon analysis of the pa- OCRIT AND METABOLIC ACI-
tient's laboratory studies, the nurse will DOSIS
expect the results to indicate what?
A) Hyperkalemia, hyponatremia, elevat- **Fluid and electrolyte changes
ed hematocrit, and metabolic acidosis in the emergent/resuscitative
B) Hypokalemia, hypernatremia, de- phase of a burn injury include hy-
creased hematocrit, and metabolic aci- perkalemia related to the release
dosis of potassium into the extracellu-
C) Hyperkalemia, hypernatremia, de- lar fluid, hyponatremia from large
creased hematocrit, and metabolic alka- amount of sodium lost in trapped
losis edema fluid, hemoconcentration
D) Hypokalemia, hyponatremia, elevated that leads to an increased hema-
hematrocrit, and metabolic alkalosis tocrit, and loss of bicarbonate
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Burn NCLEX
ions that results in metabolic aci-
dosis.
4. 4. The patient you are caring for has an MAFENIDE ACETATE

electrical burn and has developed thick 10% (SULFAMYLON) HY-
eschar over the burn wound. Which of DROPHILIC-BASED CREAM
the following topical antibacterial agents
will the nurse expect the physician to **Mafenide acetate 10% hy-
order for the wound? drophilic-based cream is
A) Silver sulfadiazine 1% (Silvadene) wa- the agent of choice for electri-
ter-soluble cream cal burns because of its ability to
B) Mafenide acetate 10% (Sulfamylon) penetrate thick eschar.
hydrophilic-based cream
C) Silver nitrate 0.5% aqueous solution
D) Acticoat
5. 5. The occupational health nurse is WRAP COOL TOWELS

called to AROUND AFFECTED EX-
the floor of the factory where a patient TREMITY INTERMITTANTLY
has sustained a flash burn to the right
arm. The nurse arrives and the flames **Once the burn has been sus-
have been extinguished. The next step is tained, the application
to "cool the burn." How will the nurse of cool water is the best first-aid
cool the burn? measure. Soaking the burn area
A) Apply ice to the site of the burn for 5 intermittently in cool water or ap-
to 10 minutes. plying cool towels gives immedi-
B) Wrap the patient's affected extremity ate and striking relief from pain
in ice until help arrives. and limits local tissue edema
C) Apply an oil-based substance or but- and damage. However, never ap-
ter to the burned area until help arrives. ply ice directly to the burn, nev-
D) Wrap cool towels around the affected er wrap the person in ice, and
extremity intermittently. never use cold soaks or dress-
ings for longer than several min-
utes; such procedures may wors-
en the tissue damage and lead to
hypothermia in people with large
burns.
6.
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Burn NCLEX
6. The emergency department nurse has 25%
just admitted a patient with a burn. The
nurse recognizes that the patient is likely **If the burn exceeds 20% to
to experience a local and systemic re- 25% TBSA, a nasogastric tube
sponse to the burn when the burn ex- is inserted and connected to low
ceeds a total body surface area (TBSA) intermittent suction. Often, pa-
of what? tients with large burns become
A) 10% nauseated as a result of the gas-
B) 15% trointestinal effects of the burn in-
C) 20% jury, such as paralytic ileus, and
D) 25% the effects of medication such as
opioids. All patients who are intu-
bated should have a nasogastric
tube inserted to decompress the
stomach and prevent vomiting.
7. 7. The nurse on a burn unit is caring for 2 DAYS

a
patient in the acute phase of burn care. **Airway obstruction caused by
While performing an assessment during upper airway edema can take
this phase of burn care, the nurse rec- as long as 48 hours to develop.
ognizes that airway obstruction related Changes detected by x-ray and
to upper airway edema may occur up to arterial blood gases may occur
how long after the burn injury? as the effects of resuscitative flu-
A) 2 days id and the chemical reaction of
B) 3 days smoke ingredients with lung tis-
C) 5 days sues become apparent.
D) A week
8. 8. A patient has sustained a severe burn EARLY AND ENTERAL FEED-

injury and is thought to have an impaired ING
intestinal mucosal barrier. Since this pa-
tient is considered at an increased risk **If the intestinal mucosa re-
for infection, what intervention will as- ceives some type of protection
sist in avoiding increased intestinal per- against permeability change, in-
meability and prevent early endotoxin fection could be avoided. Early
translocation? enteral feeding is one step to
A) Early enteral feeding help avoid this increased intesti-
B) Administration of prophylactic antibi- nal permeability and prevent ear-
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Burn NCLEX
otics ly endotoxin translocation. Antibi-
C) Bowel cleansing procedures otics are seldom prescribed pro-
D) Administration of stool softeners phylactically because of the risk
of promoting resistant strains of
bacteria. A bowel cleansing pro-
cedure would not be ordered for
this patient. The administration of
stool softeners would not assist
in avoiding increased intestinal
permeability and prevent early
endotoxin translocation.
9. 9. A patient has been admitted to a FLUID STATUS

burn intensive care unit with extensive
full-thickness burns over 25% of the **During the early phase of burn
body. What would be the nurse's priority care, the nurse is most con-
concern about this patient? cerned with fluid resuscitation,
A) Fluid status to correct large-volume fluid loss
B) Risk of infection through the damaged skin. Infec-
C) Body image tion, body image, and pain are
D) Level of pain significant areas of concern, but
are less urgent than fluid status.
10. 10. The nurse is preparing the patient USE OF SURGICAL SCIS-
for mechanical debridement and informs SORS, SCALPELS OR FOR-
the patient that this will involve: CEPS TO REMOVE THE ES-
A) A spontaneous separation of dead tis- CHAR UNTIL THE POINT OF
sue from the viable tissue PAIN AND BLEEDING OC-
B) Use of surgical scissors, scalpels or CURS
forceps to remove the eschar until the
point of pain and bleeding occurs **Mechanical debridement can
C) Shaving of burned skin layers until be achieved through the use of
bleeding, viable tissue is revealed surgical scissors, scalpels, or for-
D) Early closure of the wound ceps to remove the eschar un-
til the point of pain and bleed-
ing occurs. Mechanical debride-
ment can also be accomplished
through the use of topical enzy-
matic debridement agents. The
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Burn NCLEX
spontaneous separation of dead
tissue from the viable tissue is an
example of natural debridement.
Early wound closure and shaving
the burned skin layers are exam-
ples of surgical debridement.
11. 11. A patient with a partial-thickness TRIM AWAY THE SEPARATED

burn injury had Biobrane applied 2 BIOBRANE
weeks ago. The nurse notices that the
Biobrane is separating from the burn **As the Biobrane gradually sep-
wound. What is the appropriate nursing arates, it is trimmed, leaving a
intervention when this separation oc- healed wound. When the Bio-
curs? brane dressing adheres to the
A) Reinforce the Biobrane dressing with wound, the wound remains sta-
another piece of Biobrane. ble and the Biobrane can remain
B) Remove the Biobrane dressing and in place for 3 to 4 weeks. You
apply a new dressing. would not reinforce the Biobrane,
C) Trim away the separated Biobrane. or remove it and apply a new
D) Notify the physician for further emer- dressing. Nor would you notify
gency related orders. the physician for further orders.
12. 12. An emergency department nurse CAUSATIVE AGENT

learns from the paramedics that they are
transporting a patient who has suffered **The following factors are con-
injury from a scald from a hot kettle. sidered in determining the depth
What factors does the nurse know are of a burn: how the injury oc-
considered when determining the depth curred, causative agent (such as
of burn? flame or scalding liquid), temper-
A) Causative agent ature of the burning agent, du-
B) Visual observation of burned area ration of contact with the agent,
C) Area of body burned and thickness of the skin. To de-
D) Circumstances of the accident termine the depth of the burn
you do not take into considera-
tion you visual observation of the
burned area, how much of the
body is burned, or the circum-
stances of the accident.
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Burn NCLEX
13. 13. The nurse is caring for a patient who ACUTE PAIN
has sustained a deep partial-thickness
burn injury. In prioritizing the nursing di- **Pain is inevitable during recov-
agnoses for the plan of care, the nurse ery from any burn injury. Pain
will give the highest priority to what in the burn patient has been
nursing diagnosis? described as one of the most
A) Activity intolerance severe causes of acute pain.
B) Anxiety Management of the often-severe
C) Impaired nutrition: less than body re- pain is one of the most diffi-
quirements cult challenges facing the burn
D) Acute pain team. While the other nursing
diagnoses listed are valid diag-
noses, the presence of pain may
contribute to these diagnoses
and management of the patient's
pain is priority as it may have a di-
rect correlation to these nursing
diagnoses.
14. 14. The triage nurse in the emergency de- IMMERSE THE CHILD IN A
partment (ED) receives a phone call from COOL BATH
a frantic father who saw his 4-year-old
child tip a pot of boiling water onto her **After the flames or heat source
chest. The father has called an ambu- have been removed or extin-
lance. What would the nurse in the ED guished, the burned area and
receiving the call instruct the father to adherent clothing are soaked
do? with cool water briefly to cool
A) Cover the burn with ice and secure the wound and halt the burning
with a towel. process. Cool water is the best
B) Apply butter to the area that is burned. first-aid measure. You do not put
C) Immerse the child in a cool bath. ice on the burn, nor do you put
D) Avoid touching the burned area and butter on the burn. You do not
seek medical attention. need to avoid touching the burn.
15. 15. The nurse is teaching a patient with CONTINUOUSLY

a partial-thickness wound how to wear
his elastic pressure garment. How would Garments are worn continuously
the nurse instruct the patient to wear this (ie, 23 hours a day).
garment?
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Burn NCLEX
A) 4 to 6 hours a day for 6 months
B) Daily for 2 to 3 months after the injury
C) Continuously
D) At night while sleeping for a year after
the injury
16. 16. A patient is brought to the ED AIRWAY MANAGEMENT

by paramedics who report the patient
has partial-thickness burns on the chest **Systemic threats from a burn
and legs. The patient has also suffered are the greatest threat to life. The
smoke inhalation. What is a priority in the ABCs of all trauma care apply
care of a patient who has been burned during the early postburn peri-
and suffered smoke inhalation? od. While all options should be
A) Pain addressed, pain, fluid balance,
B) Fluid balance and anxiety and fear do not take
C) Anxiety and fear precedence over airway man-
D) Airway management agement.
17. 17. A patient arrives in the emergency de- 18%

partment after being burned in a house
fire. The patient's burns cover the face **When estimating the percent-
and the left forearm. What percentage of age of body area or burn surface
burn does the patient have? area that has been burned, the
A) 10% Rule of Nines is used: the face is
B) 25% 9%, and the forearm is 9% for a
C) 9% total of 18% in this patient.
D) 18%
18. 18. The nursing instructor is teaching SODIUM DEFICIT

about the emergent/resuscitative phase
of burn injury. During this phase, what **Anticipated fluid and elec-
would the nursing instructor tell the stu- trolyte changes that occur
dents they should closely monitor in the during the emergent/resuscita-
laboratory values? tive phase of burn injury in-
A) Sodium deficit clude potassium excess, sodium
B) Bleeding time deficit, base-bicarbonate deficit,
C) Potassium deficit and elevated hematocrit.
D) Decreased hematocrit
19.
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Burn NCLEX
19. The nursing students are doing clin- PREVENT CONTRACTURES
ical hours on the burn unit. A nurse is
developing a care plan for a patient with **To prevent the complication of
a partial-thickness burn, and determines contractures the nurse will es-
that an appropriate goal is to maintain tablish a goal to maintain posi-
position of joints in alignment. A nursing tion of joints in alignment. Gentle
student asks why this goal is important range of motion exercises and
when the patient is fighting for his life. a consult to PT and OT for ex-
What should the burn nurse respond? ercises and positioning recom-
A) To prevent neuropathies mendations are also appropriate
B) To prevent wound breakdown interventions for the prevention
C) To prevent contractures of contractures.
D) To prevent heterotopic ossification
20. 20. Grafts taken from one body and graft- HOMOGRAFT
ed onto another body are called what?
A) Allograft **Homografts are grafts derived
B) Homograft from one person's body and
C) Heterograft used on another part of a differ-
D) Autograft ent person's body.
21. 21. A nurse taking care of a burn patient YOUR BODY HAS USED YOUR
is asked why the patient is losing so FAT DEPOSITS FOR FUEL BE-
much weight. What would be the nurse's CAUSE YOU HAVEN'T BEEN
most appropriate answer? EATING VERY MUCH
A) "Your body has built up extra fat de-
posits even though you haven't been eat- **Patients lose a great deal of
ing very much." weight during recovery from se-
B) "Your body has used your fat deposits vere burns. Reserve fat deposits
for fuel because you haven't been eating are catabolized, fluids are lost,
very much." and caloric intake may be limited.
C) Your reserve fat deposits have been
catabolized because you have been eat-
ing so much."
D) You have lost fluids and you haven't
eaten very much."
22. 22. Where do most burn injuries occur? AT HOME

A) On the road
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Burn NCLEX
B) At home ** Of those people admitted to
C) At work burn centers, 47% are injured at
D) Recreational accidents home, 27% on the road, 8% are
occupational, 5% are recreation-
al, and the remaining 13% are
from other sources.
23. 23. A 45-year-old man is brought in by A, B, C

Life-Flight after a motor vehicle accident AGE, DEPTH OF THE BURN,
is which he was trapped in a burning PRESENCE OF INHALATION
vehicle. The burn team is estimating the INJURY
patient's likelihood of survival based on
the severity of the burn injury. The emer- **The severity of each burn in-
gency department nurse knows that the jury is determined by multiple
severity of the injury is based on what factors that when assessed help
factors? (Mark all that apply.) the burn team estimate the like-
A) Age lihood that a patient will survive
B) Depth of the burn and plan the care for each pa-
C) Presence of inhalation injury tient. These factors include age
D) Family support of the patient; depth of the burn;
E) Psychological state of the patient amount of surface area of the
body that is burned; presence
of inhalation injury; presence of
other injuries; location of the in-
jury in special care areas such
as the face, perineum, hands,
and feet; and presence of a past
medical history. Options D and E
are not factors that bear on the
severity of the injury.
24. 24. You have just reported to the burn A 4 YEAR OLD SCALD VICTIM
unit to start your shift. Four new pa- BURNED OVER 24% FO THE
tients have been admitted in the past BODY
12 hours. Which patient is most likely to
have life-threatening complications? **Young children and the elderly
A) A 4-year-old scald victim burned over continue to have increased mor-
24% of the body bidity and mortality when com-
B) A 27-year-old healthy male burned pared to other age groups with
10 / 17
Burn NCLEX
over 36% of his body in a car accident similar injuries and present a
C) A 39-year-old female with myasthenia challenge for burn care. This is
gravis burned over 18% of her body an important factor when deter-
D) A 60-year-old male burned over 16% mining the severity of injury and
of his body in a brush fire possible outcome for the patient.
25. 25. A burn patient is brought to the emer- HEMODYNAMIC INSTABILITY

gency department. The nurse knows that
the first systemic event after a major **The initial systemic event af-
burn injury is what? ter a major burn injury is he-
A) Hemodynamic instability modynamic instability, which re-
B) Metabolic acidosis sults from loss of capillary in-
C) Hypovolemia tegrity and a subsequent shift of
D) Hyperkalcemia fluid, sodium, and protein from
the intravascular space into the
interstitial spaces. Options B, C,
and D occur, they are just not the
first event to happen.
26. 26. A burn victim is admitted to the Inten- DISTRIBUTIVE SHOCK

sive Care Unit to stabilize and begin flu-
id resuscitation before transport to the
burn center. If inadequate fluid resuscita- Prompt fluid resuscitation main-
tion occurs what happens to the patient? tains the blood pressure in
A) Becomes unresponsive the low-normal range and im-
B) Distributive shock proves cardiac output. Despite
C) Death adequate fluid resuscitation, car-
D) Hypovolemic shock diac filling pressures (central ve-
nous pressure, pulmonary artery
pressure, and pulmonary artery
wedge pressure) remain low dur-
ing the burn-shock period. If in-
adequate fluid resuscitation oc-
curs, distributive shock occurs
27. 27. An emergency department nurse has DECREASED CARDIAC OUT-

just received a burn victim brought in by PUT
ambulance. The paramedics have start-
ed a large-bore IV and covered the burn **Pathophysiologic changes re-
11 / 17
Burn NCLEX
in cool towels. The burn is estimated sulting from major burns during
as covering 24% of the patient's body. the initial burn-shock period in-
The nurse knows that pathophysiologic clude tissue hypo-perfusion and
changes resulting from major burns dur- organ hypo-function secondary
ing the initial burn-shock period include to decreased cardiac output, fol-
what? lowed by a hyper-dynamic and
A) Hyper-dynamic anabolism hyper-metabolic phase. Options
B) Hyper-metabolic catabolism A and B are distracters for this
C) Decreased cardiac output question.
D) Organ hyper-function
28. 28. A male patient, 16 years old, comes "The burned area will start to
to the emergency department (ED) after swell in about 4 hours and blis-
burning his right hand and arm while ters will form. If you think the
working on a friend's car. The injury is dressing is too tight come back
determined to be a superficial burn and to the ED."
it is treated. What would the nurse teach
the patient before discharging him home **In a superficial burn there is
to return on a daily basis for dressing loss of capillary integrity and flu-
changes? id is localized to the burn itself,
A) "As your arm swells, push on your fin- resulting in blister formation and
gernails. If it takes longer than 5 seconds edema only in the area of injury.
for them to get pink come back to the Capillary refill should be 3 sec-
ED." onds or less. Options B and C are
B) "You should be fine until you distracters for this question.
come back tomorrow for your dressing
change."
C) "Drink lots of fluids and elevate the
arm."
D) "The burned area will start to swell in
about 4 hours and blisters will form. If
you think the dressing is too tight come
back to the ED."
29. 29. A patient is admitted to the burn unit ISCHEMIA

after being transported from a facility
1000 miles away. The patient has burns to **As edema increases, pres-
the groin area and both legs. The burns sure on small blood vessels
to the lower legs are circumferential. The and nerves in the distal extrem-
12 / 17
Burn NCLEX
nurse knows to monitor closely for what ities causes an obstruction of
as the edema in this patient increases? blood flow and consequent is-
A) Ischemia chemia. This complication is sim-
B) Eschar ilar to compartment syndrome.
C) Hyper-profusion to the burned area The physician may need to per-
D) Increased fluid loss through the form an escharotomy, a surgical
burned area incision into the eschar (devital-
ized tissue resulting from a burn),
to relieve the constricting effect
of the burned tissue.
30. 30. A nurse on the burn unit is caring for HYPONATREMIA

a patient who has gone into the acute
phase of her burn. What would be impor- **Hyponatremia is common dur-
tant for the nurse to monitor the patient ing the first week of the acute
for? phase, as water shifts from the
A) Hypometabolism interstitial space to the vascu-
B) Hyponatremia lar space. Hypermetabolism can
C) Hyperkalemia occur up to 1 year after the
D) Hypoglycemia burn. Hyperkalemia occurs in the
emergent phase of the burn. In
a burn patient there is a hyper-
glycemic response, not a hypo-
glycemic response.
31. 31. The acute phase of the burn begins DIURESIS

48 to 72 hours after the burn. What be-
gins at this time? **As capillaries regain integrity,
A) Cardiac output decreases 48 or more hours after the burn,
B) Renal failure begins fluid moves from the interstitial
C) Diuresis to the intravascular compartment
D) Fluid moves from intravascular com- and diuresis begins. Cardiac out-
partment to interstitial spaces put should increase and renal
output should increase.
32. 32. As the patient begins the acute phase C) Patient's physiologic respons-
of a burn, cautious administration of flu- es to the burn injury
ids and electrolytes continues. The nurse D) Losses of fluid from large burn
knows that this caution is because of wounds
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Burn NCLEX
what? (Mark all that apply.) E) Shifts in fluid from the intersti-
A) Patient is considered in critical condi- tial to the intravascular compart-
tion ment
B) Cardiac function is decreased
C) Patient's physiologic responses to the **Cautious administration of flu-
burn injury ids and electrolytes continues
D) Losses of fluid from large burn during this phase of burn care
wounds because of the shifts in fluid from
E) Shifts in fluid from the interstitial to the interstitial to the intravascu-
the intravascular compartment lar compartment, losses of fluid
from large burn wounds, and the
patient's physiologic responses
to the burn injury.
33. 33. What is the nursing goal during the TO ULTIMATELY PREVENT OR
acute phase of a burn? CONTROL INFECTION IN THE
A) To ultimately prevent or control infec- BURN POPULAITON
tion in the burn population
B) To prevent hypervolemia in the burn **The nursing goal is to provide
population protection and safety in the pa-
C) To manage pain in a proactive way for tients' environment to ultimately
the patient's comfort prevent or control infection in the
D) To provide emotional support as the burn population. This makes op-
changes in body image become internal- tions B, C, and D incorrect.
ized in the patient
34. 34. A nurse is caring for a patient during CLOSELY SCRUTINIZING THE
the acute phase of the burn. The nurse BURN WOUND TO DETECT
knows he is responsible for what? EARLY SIGNS OF INFECTION
A) Restricting visitors to prevent infec-
tion **The nurse is responsible for
B) Closely scrutinizing the burn wound providing a clean and safe en-
to detect early signs of infection vironment and for closely scruti-
C) Cleaning the patient's room nizing the burn wound to detect
D) Maintaining the patient in a sterile en- early signs of infection. Visitors
vironment are not restricted to a burn pa-
tient. The nurse does not clean
the patient's room. The patient
14 / 17
Burn NCLEX
is maintained in a clean environ-
ment, not a sterile environment.
35. 35. It is time to change the dressings on THE NURSE CHANGES

a burn patient. What does the nurse do to DRESSINGS AS QUICKLY AS
reduce pain and discomfort at this time? POSSIBLE
A) The nurse lets the patient decide on
when to change the dressing. **The nurse works quickly to
B) The nurse skip's the dressing change complete treatments and dress-
if the patient is really uncomfortable. ing changes to reduce pain and
C) The nurse changes dressings as discomfort. Letting the patient
quickly as possible. decide the time of the dress-
D) The nurse lets the aide do the painful ing change lets the patient feel
part of the dressing change. more in control. It doesn't re-
duce pain and discomfort. The
nurse should never skip an or-
dered dressing change. You nev-
er delegate a dressing change
on a burn patient.
36. 36. You are caring for a burn patient who PREVENTION OF DVT
is in the later stages of the acute phase
of the burn injury. What is an important **Prevention of deep vein throm-
factor in your care of the patient? bosis (DVT) is an important fac-
A) Immobilizing the patient tor in care. Early mobilization
B) Maintaining splints and functional de- of the patient is important. The
vices nurse monitors the splints and
C) Maintaining ongoing discussion functional devices, but does not
about the patient with a psychologist maintain them. The nurse does
D) Prevention of DVT not maintain discussion with a
psychologist about the patient.
37. 37. Your patient is in the acute phase of A,C,E

a burn injury. One of the nursing diag-
noses on the plan of care is ineffective PROMOTE TRUTHFUL CO-
coping due to burn injury and altered MUNICATION, ASSIST THE
body image. What interventions can you PATIENT IN PRACTICING
institute to help this patient cope more APPROPRIATE STRATEGIES,
effectively? (Mark all that apply.) GIVE POSITIVE REINFORCE-
15 / 17
Burn NCLEX
A) Promote truthful communication MENT WHEN APPROPRIATE
B) Allowing the patient to set specific **The nurse can assist the pa-
expectations tient to develop effective cop-
C) Assist the patient in practicing appro- ing strategies by setting specif-
priate strategies ic expectations for behavior, pro-
D) Stop the patient's manipulation of moting truthful communication to
staff build trust, helping the patient
E) Give positive reinforcement when ap- practice appropriate strategies,
propriate and giving positive reinforcement
when appropriate. The nurse
should set specific expectations,
not the patient. Each staff mem-
ber needs to stop the manipu-
lation of the patient with the in-
volved staff member.
38. 38. What is a priority in the rehabilitation PATIENT AND FAMILY EDUCA-
phase of the burn injury? TION
A) Monitoring fluid and electrolyte imbal-
ances **Patient and family education is
B) Patient and family education a priority in the acute and re-
C) Assessing wound healing habilitation phases. There should
D) Documenting family support be no fluid and electrolyte imbal-
ances in the rehabilitation phase.
Assessing wound healing is an
ongoing function but it is not
a priority in the rehabilitation
phase. Documenting family sup-
port is not a priority in the reha-
bilitation phase.
39. 39. A burn patient is transitioning from YOU KNOW, NOTHING CAN
the acute phase of the injury to the re- BE DONE UNTIL YOUR SCARS
habilitation phase. The patient tells the MATURE. IT IS SOMETHING
nurse "I can't wait to have surgery to THE DOCTOR WILL TALK TO
reconstruct my face so I look normal YOU ABOUT IN THE FIRST
again." What would be the nurse's best FEW YEARS AFTER DIS-
response? CHARGE
A) "You know, nothing can be done until
16 / 17
Burn NCLEX
your scars mature. It is something the **Burn reconstruction is a treat-
doctor will talk to you about in the first ment option after all scars have
few years after discharge." matured and is discussed with-
B) "That is something for you to talk to in the first few years after injury.
your doctor about." Options B and C are true state-
C) "I know this is really important to you, ments but not the best state-
but you have to realize that no one can ments. The nurse does not know
make you look like you used to." for sure how much reconstruc-
D) "You will have most of these scars for tion can be done.
the rest of your life."
40. 40. A patient in the rehabilitation phase A, B, D

of the burn injury is setting goals with INCREASED PARTICIPATION
the nurse. What goals would be appropri- IN ADLs, INCREASED UNDER-
ate at this time? (Mark all that apply.) STANDING OF THE PLANNED
A) Increased participation in activities of FOLLOW-UP CARE, ADJUST-
daily living MENT TO ALTERATIONS IN
B) Increased understanding of the LIFESTYLE
planned follow-up care
C) Increased control of treatment **The major goals for the patient
D) Adjustment to alterations in lifestyle include increased participation in
E) Recognition of complications activities of daily living; increased
understanding of the injury, treat-
ment, and planned follow-up
care; adaptation and adjustment
to alterations in body image,
self-concept, and lifestyle; and
absence of complications.
17 / 17

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Burn NCLEX

Study online at https://quizlet.com/_q7xn3

1. 1. A patient is brought to the Emergency FULL THICKNESS

2. 2. The nursing instructor is going over ACUTE

3. 3. A patient in the emergent/resuscitative HYPERKALEMIA, HYPONA-

4. 4. The patient you are caring for has an MAFENIDE ACETATE

5. 5. The occupational health nurse is WRAP COOL TOWELS

7. 7. The nurse on a burn unit is caring for 2 DAYS

8. 8. A patient has sustained a severe burn EARLY AND ENTERAL FEED-

9. 9. A patient has been admitted to a FLUID STATUS

11. 11. A patient with a partial-thickness TRIM AWAY THE SEPARATED

12. 12. An emergency department nurse CAUSATIVE AGENT

15. 15. The nurse is teaching a patient with CONTINUOUSLY

16. 16. A patient is brought to the ED AIRWAY MANAGEMENT

17. 17. A patient arrives in the emergency de- 18%

18. 18. The nursing instructor is teaching SODIUM DEFICIT

22. 22. Where do most burn injuries occur? AT HOME

23. 23. A 45-year-old man is brought in by A, B, C

25. 25. A burn patient is brought to the emer- HEMODYNAMIC INSTABILITY

26. 26. A burn victim is admitted to the Inten- DISTRIBUTIVE SHOCK

27. 27. An emergency department nurse has DECREASED CARDIAC OUT-

29. 29. A patient is admitted to the burn unit ISCHEMIA

30. 30. A nurse on the burn unit is caring for HYPONATREMIA

31. 31. The acute phase of the burn begins DIURESIS

35. 35. It is time to change the dressings on THE NURSE CHANGES

37. 37. Your patient is in the acute phase of A,C,E

40. 40. A patient in the rehabilitation phase A, B, D

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