NCLEX Questions On Burn Injury Nursing Management

1. Which laboratory result. obtained on a client 24 hours post-burn injury. will the nurse report to the physician immediately?

Arterial pH. 7.32

Hematocrit. 52%

Serum potassium.7.5 mmol/L (mEq/L)

Serum sodium. 131 mmol/L (mEq/L)

The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level. the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal. but not to the same degree of severity. and would be expected in the emergent phase after a burn injury.

Explanation

The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level. the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal. but not to the same degree of severity. and would be expected in the emergent phase after a burn injury.

2. Which statement best exemplifies the client's understanding of rehabilitation after a full-thickness burn injury?

“I am fully recovered when all the wounds are closed.”

“I will eventually be able to perform all my former activities.”

“My goal is to achieve the highest level of functioning that I can.”

“There is never full recovery from a major burn injury.”

Although a return to pre-burn functional levels is rarely possible. burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical. social. and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

Explanation

Although a return to pre-burn functional levels is rarely possible. burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical. social. and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

3. Which finding is characteristic during the emergent period after a deep full thickness burn injury?

Blood pressure of 170/100 mm Hg

Foul-smelling discharge from wound

Pain at site of injury

Urine output of 10 mL/hr

During the fluid shift of the emergent period. blood flow to the kidney may not be adequate for glomerular filtration. As a result. urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.

Explanation

During the fluid shift of the emergent period. blood flow to the kidney may not be adequate for glomerular filtration. As a result. urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.

4. Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color. edematous. and without pain?

Decreased Tissue Perfusion

Disturbed Body Image

Risk for Disuse Syndrome

Risk for Ineffective Breathing Pattern

During the emergent phase. fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity. the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury. causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However. these are not priority diagnoses at this time.

Explanation

During the emergent phase. fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity. the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury. causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However. these are not priority diagnoses at this time.

5. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action?

Administer oxygen.

Loosen the dressing.

Notify the emergency team.

Document the observation as the only action.

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status.

Explanation

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status.

6. Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

Changing gloves between wound care on different parts of the client’s body.

Avoiding sharing equipment such as blood pressure cuffs between clients.

Using the closed method of burn wound management.

Using proper and consistent handwashing.

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body. causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection. only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

Explanation

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body. causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection. only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

7. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

Seasonal asthma

Hepatitis B 10 years ago

Myocardial infarction 1 year ago

Kidney stones within the last 6 month

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

Explanation

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

8. Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment?

“My facial scars should be less severe with the use of this mask.”

“The mask will help protect my skin from sun damage.”

“This treatment will help prevent infection.”

“Using this mask will prevent scars from being permanent.”

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive. newly healed skin and grafts from sun exposure. this is not the purpose for wearing the mask. The pressure garment will not alter the risk for infection.

Explanation

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive. newly healed skin and grafts from sun exposure. this is not the purpose for wearing the mask. The pressure garment will not alter the risk for infection.

9. During the acute phase. the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

Increased wound pain 30 to 40 minutes after drug application

Presence of small. pale pink bumps in the wound beds

Decreased white blood cell count

Increased serum creatinine level

Gentamicin does not stimulate pain in the wound. The small. pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

Explanation

Gentamicin does not stimulate pain in the wound. The small. pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

10. Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury?

Allowing the client to eat whenever he or she wants

Beginning parenteral nutrition high in calories

Limiting calories to 3000 kcal/day

Providing a low-protein. high-fat diet

Clients should request food whenever they think that they can eat. not just according to the hospital’s standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie. high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.

Explanation

Clients should request food whenever they think that they can eat. not just according to the hospital’s standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie. high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.