Burn Injury Nursing Management Quiz: NCLEX Preparation

1. The nurse is administering fluids intravenously as ordered to a client who acquired full-thickness burn injury on the abdomen. To determine the sufficiency of fluid resuscitation. the nurse would monitor which of the following that would provide the most reliable parameter for determining the adequacy?

Level of consciousness.

Peripheral pulses.

Urine output.

Vital signs.

Of all the options. Urine output is the most reliable indicator for determining the adequacy of fluid resuscitation.

Explanation

Of all the options. Urine output is the most reliable indicator for determining the adequacy of fluid resuscitation.

2. Nurse Rodrigo is receiving an endorsement from the burn unit. Which of the following clients should he assess first?

A client who has just been transferred from the PACU after having allograft.

A client admitted 1 week ago with a superficial-thickness burn on the buttocks which has been waiting for 2 hours to receive discharge instructions.

A client who has just arrived from the emergency department with burns on the neck and chest.

A client with deep partial-thickness burns on both thighs who is complaining of severe and continuous pain.

Burns of the neck and chest are associated with inflammation and swelling of the airway. Hence this patient requires the most immediate attention.

Explanation

Burns of the neck and chest are associated with inflammation and swelling of the airway. Hence this patient requires the most immediate attention.

3. The nurse is caring for a client with a burn wound on the left knee and an autograft and skin grafting was performed. Which of the following activity will be prescribed for the client post op?

Elevation and immobilization of the affected leg.

Placing the affected leg in a dependent position.

Dangling of legs.

Bathroom privileges.

Autograft placed on the lower extremity requires elevation and immobilization for at least 3-7days. This period of immobilization allows the autograft time to adhere to the wound bed.

Explanation

Autograft placed on the lower extremity requires elevation and immobilization for at least 3-7days. This period of immobilization allows the autograft time to adhere to the wound bed.

4. The nurse is handling a client who sustained electrical burn on the arm and wrist and is scheduled for a fasciotomy. After the procedure. the nurse should assess the affected extremity in which of the following EXCEPT?

Sensation.

Color.

Distal circulation.

All of the above.

Following fasciotomy. the nurse should assess pulses. color. sensation. and movement of the affected extremity as well as bleeding.

Explanation

Following fasciotomy. the nurse should assess pulses. color. sensation. and movement of the affected extremity as well as bleeding.

5. Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed?(1. Cover the wound using a sterile gauze dressing.|| 2. Administer Tramadol (Tramal) 50 mg IV.|| 3. Debride the wound of eschar using gauze sponges.|| 4. Apply silver nitrate ointment.|| 5. Obtain sample for wound culture.

2.5.4.3.1

2.3.5.4.1

5.2.3.1.4

5.4.3.1.2

A pain medication is administered prior the dressing change since the type of burn will be painful during the procedure. Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Lastly. cover the wound using a sterile dressing.

Explanation

A pain medication is administered prior the dressing change since the type of burn will be painful during the procedure. Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Lastly. cover the wound using a sterile dressing.

6. Nurse Cirie is caring for a client who suffered a smoke inhalation injury. The carbon monoxide report reveals a level of 35%. Based on the level. which of the following signs should the nurse expect in the client?

Seizure.

Confusion.

Flushing.

Coma.

Signs and Symptoms of carbon monoxide levels between 21-40% (moderate poisoning) include hypotension. tachycardia. headache. drowsiness. confusion. nausea. and vomiting.Options A and D: Carbon monoxide levels of 41% to 60% result in seizure and coma.Option C: Carbon monoxide levels of 11% to 20% result in flushing.

Explanation

Signs and Symptoms of carbon monoxide levels between 21-40% (moderate poisoning) include hypotension. tachycardia. headache. drowsiness. confusion. nausea. and vomiting.Options A and D: Carbon monoxide levels of 41% to 60% result in seizure and coma.Option C: Carbon monoxide levels of 11% to 20% result in flushing.

7. Which of the following medications given to a 12-year-old client for the treatment of deep partial thickness burn is the most important to double check with another licensed nurse before administering it?

Aloe Vera Relief Burn spray.

Silver Sulfadiazine ointment.

Omeprazole 20 mg slow IV push.

Amitriptyline (Elavil) 50 mg PO.

Amitriptyline (Elavil) is useful in the management of neuropathic pain following burn injury and since it is an antidepressant if given with a child. utmost precaution is given.Options A. B. and C: All health facility practice double checking of medications prior administration. Of all the medications given. Amitriptyline is the most important to double check with another licensed nurse.

Explanation

Amitriptyline (Elavil) is useful in the management of neuropathic pain following burn injury and since it is an antidepressant if given with a child. utmost precaution is given.Options A. B. and C: All health facility practice double checking of medications prior administration. Of all the medications given. Amitriptyline is the most important to double check with another licensed nurse.

8. A client is brought to the emergency unit with third-degree burns on the posterior trunk. right arm. and left posterior leg. Using the Rule of Nines. what is the total body surface area that has been burned?

36%.

54%.

45%.

27%.

Based on the rule of nines. with posterior trunk equals 18%. right arm equals 9%. and left posterior leg equals 9%. Therefore. a total of 36%.

Explanation

Based on the rule of nines. with posterior trunk equals 18%. right arm equals 9%. and left posterior leg equals 9%. Therefore. a total of 36%.

9. A medicine student arrives at the emergency unit due to a burn injury that occurred inside the laboratory and an inhalation injury is suspected. Which of the following is the appropriate oxygen therapy for the client?

Oxygen via nasal cannula at 5 L/min.

Oxygen via a tight fitting. non-rebreather face mask at 100% concentration.

Oxygen via nasal cannula at 10 L/min.

Oxygen via Venturi mask at 30% Fi02.

If an inhalation injury is suspected. management includes the administration of oxygen via a tight fitting. non-rebreather face mask at 100% concentration. This is prescribed until carboxyhemoglobin levels in the blood fall below 15%.

Explanation

If an inhalation injury is suspected. management includes the administration of oxygen via a tight fitting. non-rebreather face mask at 100% concentration. This is prescribed until carboxyhemoglobin levels in the blood fall below 15%.

10. Which of the following route should the nurse expect the pain medication to be given to a client who was admitted with extensive burns?

Oral.

Intramuscular.

Subcutaneous.

Intravenous.

For clients with major burns. the intravascular route is the preferred choice of medicine administration.Options A and B: An extensive burn injury causes damage to the muscle and subcutaneous area.Option D: Due to the burn injury. the gastrointestinal tract will have decreased perfusion hence relief of pain will not be experienced.

Explanation

For clients with major burns. the intravascular route is the preferred choice of medicine administration.Options A and B: An extensive burn injury causes damage to the muscle and subcutaneous area.Option D: Due to the burn injury. the gastrointestinal tract will have decreased perfusion hence relief of pain will not be experienced.