BURN NCLEX EXAM 2023-2024 QUESTIONS WITH ANSWERS AND RATIONALES
1. A nurse is caring for a client who has full-thickness burns covering 63% of her body
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smoke inhalation. Which of the following nursing actions is top priority?
A. Monitor intake and output
B. Administer antibiotics
C. Monitor respiratory status
D. Encourage fluid and food intake
Correct Answer is C. Monitor Respiratory Status
The priority action for the nurse when using airway, breathing, and circulation (ABC)
approach to client care is to monitor the client’s respiratory status closely. Smoke
inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from
the inflammatory response to heat can obstruct the airway. Endotracheal intubation may
become necessary to maintain a patient airway.
Incorrect Answers
A. The nurse should monitor the client’s intake and output because clients who have
sustained major burns quickly dehydrate as a result of the fluid shift from the
vascular system into the interstitial space; however, another action is the priority.
B. Infection is serious health risk for clients who sustained major burns, and antibiotic
therapy is probable; however, another action is the priority.
C. Nutritional support is essential for clients who sustained major burns, although they
might receive nutrients via IV or enteral tube initially; another action is the priority
2. A nurse is planning care for a client who has deep partial-thickness and full-thickness
thermal burns over 40% of his total body surface and is in the acute phase of burn injury.
Which of the following interventions should the nurse include in the plan?
A. Initiate range of motion exercises
B. Use clean technique to provide wound care
C. Place the client on low protein diet
D. Maintain the client on bed rest
Correct Answer: A. Initiate range of motion exercises
The nurse should begin performing active and passive range of motion exercises with the
client to maintain mobility and prevent contractures.
Incorrect Answers:
B. The nurse should use sterile technique to provide wound care for this client to
reduce the risk of infection.
C. The nurse should place the client on a high-protein, high-calorie diet to promote
wound healing.
D. The nurse should encourage the client to ambulate frequently to promote mobility
and improve ventilation.
3. A nurse is caring for an adolescent client who has burn wounds on her face and hands.
Which of the following statements by the client indicates that she has adapted to her
changed body image?
A. “May I go with my family to visitor’s lounge?”
B. “I’ll see my friends when I get home”
C. “My dad is coming to visit me. Can you fix my hair for me?” [Show Less]