Burns NCLEX Questions #1 (25 Questions)

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Burns NCLEX Questions 1

Rationale: Immobilizing the client’s hands with splints is essential to prevent contractures, as burns to the hands can result in scar tissue formation and limited mobility.

#2. When caring for a client with full-thickness burns, the nurse should anticipate which priority intervention?

Applying a topical antimicrobial cream Applying a topical antimicrobial cream Administering intravenous fluids Administering intravenous fluids Assessing the client's pain level Assessing the client's pain level Initiating enteral nutrition Initiating enteral nutrition

Administering intravenous fluids is the priority intervention for clients with full-thickness burns to maintain adequate fluid balance and prevent hypovolemic shock.

#3. A client is admitted to the emergency department with suspected inhalation injury. Which intervention should the nurse prioritize?

Administering oxygen therapy Administering oxygen therapy Obtaining a complete blood count Obtaining a complete blood count Assessing arterial blood gas values Assessing arterial blood gas values Initiating prophylactic antibiotic therapy Initiating prophylactic antibiotic therapy

Administering oxygen therapy is the priority intervention for a client with suspected inhalation injury to improve oxygenation and respiratory function.

#4. A client with burns sustained in a house fire is brought to the emergency department. The nurse notes darkened oral and nasal mucosa upon assessment. Which action should the nurse take?

Administering a bronchodilator medication Administering a bronchodilator medication Administering humidified oxygen therapy Administering humidified oxygen therapy Providing intravenous antibiotics Providing intravenous antibiotics Placing the client in a high-Fowler's position Placing the client in a high-Fowler's position

Administering humidified oxygen therapy is necessary for clients with darkened oral and nasal mucosa due to smoke inhalation, as it helps humidify the respiratory tract and improve gas exchange.

#5. A client with burns to the lower extremities is scheduled for debridement. Which intervention should the nurse perform before the procedure?

Administer a premedication for pain Administer a premedication for pain Obtain a wound culture for analysis Obtain a wound culture for analysis Apply a topical antibiotic ointment Apply a topical antibiotic ointment Elevate the client's legs on pillows Elevate the client's legs on pillows

Administering a premedication for pain is essential before debridement to ensure the client’s comfort during the procedure.

#6. The nurse is teaching a client about wound care for partial-thickness burns. Which statement by the client indicates a need for further education?

"I should clean the wound with mild soap and water." "I should clean the wound with mild soap and water." "I will apply a sterile dressing to the wound." "I will apply a sterile dressing to the wound." "I can use over-the-counter antibiotic ointment on the burn." "I can use over-the-counter antibiotic ointment on the burn." "I need to change the dressing daily to promote healing." "I need to change the dressing daily to promote healing."

“I need to change the dressing daily to promote healing” is incorrect because daily dressing changes can disrupt the healing process. Dressing changes for partial-thickness burns are typically performed every 2-3 days.

#7. The nurse is assessing a client with full-thickness burns to the face and chest. Which finding requires immediate intervention?

Pain and discomfort Pain and discomfort Swollen and edematous face Swollen and edematous face Singed nasal hair and hoarse voice Singed nasal hair and hoarse voice Elevated body temperature Elevated body temperature

Singed nasal hair and hoarse voice suggest inhalation injury, which requires immediate intervention due to potential airway compromise.

#8. A client with burns is prescribed silver sulfadiazine cream. What is the primary purpose of this medication?

To provide analgesia to the burn site To provide analgesia to the burn site To prevent infection in the burn wound To prevent infection in the burn wound To promote granulation tissue formation To promote granulation tissue formation To remove necrotic tissue from the wound To remove necrotic tissue from the wound

Silver sulfadiazine cream is used to prevent infection in burn wounds due to its antimicrobial properties.

#9. A client is being treated for partial-thickness burns to the upper body. Which laboratory result should the nurse monitor closely?

Platelet count Platelet count Serum glucose level Serum glucose level White blood cell count White blood cell count Serum potassium level Serum potassium level

White blood cell count should be monitored closely for signs of infection, as the client is at risk for developing sepsis.

#10. A client with burns is experiencing anxiety and restlessness. Which intervention should the nurse implement first?

Administering an anxiolytic medication Administering an anxiolytic medication Providing a quiet and calm environment Providing a quiet and calm environment Encouraging the client to verbalize feelings Encouraging the client to verbalize feelings Administering a pain medication Administering a pain medication

Providing a quiet and calm environment is the initial intervention to promote relaxation and reduce anxiety in a client with burns.

#11. A client with burns is at risk for impaired skin integrity. Which action should the nurse take to prevent skin breakdown?

Apply a thin layer of petroleum jelly to the affected areas Apply a thin layer of petroleum jelly to the affected areas Turn and reposition the client every 2 hours Turn and reposition the client every 2 hours Encourage the client to increase fluid intake Encourage the client to increase fluid intake Provide a high-protein diet to promote tissue repair Provide a high-protein diet to promote tissue repair

Turning and repositioning the client every 2 hours helps prevent pressure ulcers and skin breakdown in clients with burns.

#12. A client is admitted to the burn unit with full-thickness burns. Which priority intervention should the nurse implement first?

Administering tetanus prophylaxis Administering tetanus prophylaxis Administering intravenous analgesics Administering intravenous analgesics Initiating fluid resuscitation Initiating fluid resuscitation Cleaning and debriding the wound Cleaning and debriding the wound

Initiating fluid resuscitation is the priority intervention in clients with full-thickness burns to restore fluid balance and prevent hypovolemic shock.

#13. A client with burns has an open wound that is not healing well. Which nutrient deficiency should the nurse suspect?

Vitamin C deficiency can impair wound healing, collagen synthesis, and tissue repair in clients with burns.

#14. A client with partial-thickness burns is prescribed a topical antimicrobial cream. What is the primary purpose of this medication?

To provide analgesia to the burn site To provide analgesia to the burn site To promote wound healing and tissue repair To promote wound healing and tissue repair To prevent infection in the burn wound To prevent infection in the burn wound To minimize scarring and contractures To minimize scarring and contractures

A topical antimicrobial cream is used to prevent infection in burn wounds and reduce the risk of complications.

#15. The nurse is caring for a client with full-thickness burns. Which finding requires immediate intervention?

Urine output of 20 mL/hr Urine output of 20 mL/hr Serum sodium level of 135 mEq/L Serum sodium level of 135 mEq/L Heart rate of 110 beats per minute Heart rate of 110 beats per minute Blood pressure of 90/60 mmHg Blood pressure of 90/60 mmHg

A blood pressure of 90/60 mmHg suggests hypovolemia and requires immediate intervention to prevent hypovolemic shock.

#16. A client with burns is receiving fluid resuscitation. Which assessment finding should the nurse report immediately?

Urine output of 50 mL/hr Urine output of 50 mL/hr Presence of crackles in the lungs Presence of crackles in the lungs Serum potassium level of 3.5 mEq/L Serum potassium level of 3.5 mEq/L Heart rate of 90 beats per minute Heart rate of 90 beats per minute

The presence of crackles in the lungs suggests fluid overload, which can occur as a complication of fluid resuscitation. It should be reported immediately.

#17. A client with burns is prescribed a nonsteroidal anti-inflammatory drug (NSAID) for pain management. Which instruction should the nurse provide to the client?

"Take the medication on an empty stomach." "Take the medication on an empty stomach." "Avoid taking this medication with milk." "Avoid taking this medication with milk." "Take the medication with a full glass of water." "Take the medication with a full glass of water." "Avoid taking this medication with antacids." "Avoid taking this medication with antacids."

“Take the medication on an empty stomach” is the correct instruction for clients taking NSAIDs, as taking them with food can decrease their effectiveness.

#18. The nurse is caring for a client with partial-thickness burns. Which action should the nurse take when changing the client's dressings?

Remove the dressing gently to prevent further tissue damage Remove the dressing gently to prevent further tissue damage Cleanse the wound with hydrogen peroxide solution Cleanse the wound with hydrogen peroxide solution Apply sterile gloves before removing the old dressing Apply sterile gloves before removing the old dressing Use sterile forceps to remove any loose debris Use sterile forceps to remove any loose debris

Removing the dressing gently to prevent further tissue damage is crucial when changing the dressings for clients with partial-thickness burns.

#19. A client with burns is prescribed silver-impregnated dressings. What is the primary purpose of these dressings?

To promote wound healing and tissue repair To promote wound healing and tissue repair To prevent infection in the burn wound To prevent infection in the burn wound To provide analgesia to the burn site To provide analgesia to the burn site To minimize scarring and contractures To minimize scarring and contractures

Silver-impregnated dressings are used to prevent infection in burn wounds due to their antimicrobial properties.

#20. A client with burns is scheduled for a dressing change. Which intervention should the nurse implement during the procedure?

Administering intravenous antibiotics Administering intravenous antibiotics Administering an analgesic before the procedure Administering an analgesic before the procedure Applying a topical corticosteroid cream Applying a topical corticosteroid cream Administering tetanus prophylaxis Administering tetanus prophylaxis

Administering an analgesic before the procedure is necessary to ensure the client’s comfort during the painful dressing change.

#21. A client with burns is receiving fluid resuscitation. The nurse suspects fluid overload based on which assessment finding?

Decreased urine output Decreased urine output Hypotension Hypotension Dry oral mucosa Dry oral mucosa Peripheral edema Peripheral edema

Peripheral edema suggests fluid overload and should be assessed when monitoring clients receiving fluid resuscitation.

#22. A client with burns has a positive Homans' sign during the assessment. What does this finding indicate?

Infection in the burn wound Infection in the burn wound Deep vein thrombosis Deep vein thrombosis Peripheral neuropathy Peripheral neuropathy Allergic reaction to dressing material Allergic reaction to dressing material

A positive Homans’ sign indicates the possibility of a deep vein thrombosis (DVT) and should be further investigated.

#23. A client with burns is experiencing severe pain. Which medication should the nurse anticipate administering?

Acetaminophen Acetaminophen

Fentanyl is a potent opioid analgesic commonly used for severe pain relief in clients with burns.

#24. A client with burns is receiving enteral nutrition. Which action should the nurse take to prevent aspiration during feeding?

Administer the feedings through a nasogastric tube Administer the feedings through a nasogastric tube Place the client in a supine position during feedings Place the client in a supine position during feedings Elevate the head of the bed at a 45-degree angle Elevate the head of the bed at a 45-degree angle Provide the feedings at room temperature Provide the feedings at room temperature

Elevating the head of the bed at a 45-degree angle during feedings helps prevent aspiration in clients with burns.

#25. A client with burns asks the nurse about the risk of infection. Which response by the nurse is appropriate?

"Burn wounds are not prone to infection." "Burn wounds are not prone to infection." "Infection is a common complication of burns." "Infection is a common complication of burns." "You don't need to worry about infection if you keep the wound dry." "You don't need to worry about infection if you keep the wound dry." "Infection usually occurs only in deep burns." "Infection usually occurs only in deep burns."

“Infection is a common complication of burns” is an appropriate response, as burn wounds are highly susceptible to infection, especially when not properly managed and treated.

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