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Nursing Care of Clients with Burns
NCLEX Review

1 .       A nurse, admitting a client burned with a flash flame, observes a burned area which is bright red, with a moist, glistening appearance and blister formation. The area blanches upon pressure, and the client complains of severe pain upon exposure of the site to air. The nurse recognizes that the depth of the burn is categorized as which of the following? [Hint]

 
 
 
 


2 .       A client presents with deep partial-thickness burns to the anterior trunk and left anterior arm, and full-thickness burns to the anterior left leg and perineum, and superficial burns to the right anterior leg. The nurse calculates the percentage of TBSA burned as which of the following? [Hint]

 
 
 
 


3 .       A nurse in the emergency department is assigning triage classifications to 4 clients admitted with burn injuries sustained in a house fire. Which of the following clients would the nurse identify as a minor burn versus a major burn? [Hint]

 
 
 
 


4 .       A client with major burn injuries 45% of TBSA is admitted to the burn unit. The nurse planning care knows that the client will likely experience which of the following in the emergent phase? [Hint]

 
 
 
 


5 .       A young adult male is rescued from a burning building after he was found by firefighters in an enclosed room with no ventilation. The victim is confused, hypotensive, bradycardic, and his skin coloring is dark red. Based on this assessment data, the rescuers would suspect which of the following? [Hint]

 
 
 
 


6 .       A client in the burn unit complains of abdominal pain followed by hematemesis. The nurse assesses the client, and bowel sounds are auscultated in all quadrants and the abdomen is soft and non-distended. The nurse planning care for this client would suspect that the client is experiencing which of the following? [Hint]

 
 
 
 


7 .       A young adult woman calls the emergency department for advice on emergency treatment of her husband who just spilled a large amount of powder chemical on his arms and trunk. Which of the following is the nurse's most appropriate course of action? [Hint]

 
 
 
 


8 .       A nurse is calculating the fluid recommendations for a burn victim with burns estimated at 40% of TBSA. Using the Parkland formula and the client's weight of 82 kg, which of the following is the suggested fluid volume replacement protocol? [Hint]

 
 
 
 


9 .       A burn victim is being treated by emergency medical personnel at the location of the injury. The medical personnel note that the victim has sustained severe burns to the face, neck, and trunk. The victim is responsive at this time and complains of difficulty breathing. Which of the following is the most appropriate immediate action? [Hint]

 
 
 
 


10 .       A client with a circumferential burn to the left arm complains of severe pain to the arm. The nurse assesses the client and notes the arm to be cool, notes a diminished capillary refill, and has difficulty locating the radial pulse by Doppler. Which of the following represents the nurse's most appropriate action? [Hint]

 
 
 
 






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