A 28-year-old patient is admitted to the emergency department with second-degree burns on the hands and arms sustained from a kitchen accident. The nurse prioritizes wound care. What is the most appropriate initial intervention?
a) Apply ice packs to the affected areas.
b) Administer an analgesic before dressing changes.
c) Cleanse the burns with hydrogen peroxide.
d) Remove any blisters that have formed.
e) Apply a thick layer of petroleum jelly to the burns.
Rationale: Administering an analgesic before dressing changes helps manage pain and discomfort, promoting better compliance with wound care. Ice packs can worsen tissue damage, hydrogen peroxide may delay healing, removing blisters increases infection risk, and petroleum jelly can trap heat, exacerbating the burns.
POP QUIZ NCLEX Question
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A 40-year-old patient with third-degree burns over 20% of the body is receiving fluid resuscitation. The nurse monitors for complications related to fluid imbalance. Which assessment finding indicates a potential complication?
a) Increased urine output.
b) Crackles on lung auscultation.
c) Cool extremities.
d) Hypertension.
e) Decreased heart rate.
Rationale: Crackles suggest fluid overload and pulmonary edema, a potential complication of aggressive fluid resuscitation in burn patients. Increased urine output is a positive response, while cool extremities, hypertension, and decreased heart rate are not specific signs of fluid overload.
Understanding Burn Injuries: Causes and Symptoms, NCLEX Priority Questions
A pediatric patient is brought to the clinic with a scald burn. The nurse assesses the burn depth to determine the appropriate interventions. Which characteristic is indicative of a superficial partial-thickness burn?
a) Absence of pain.
b) White and waxy appearance.
c) Blister formation.
d) Charring of the skin.
e) Involvement of subcutaneous tissue.
Rationale: Superficial partial-thickness burns involve the epidermis and part of the dermis, leading to blister formation. Absence of pain is more characteristic of full-thickness burns, while white and waxy appearance, charring of the skin, and involvement of subcutaneous tissue are indicative of deeper burns.
A 35-year-old patient presents to the emergency room with thermal burns sustained in a house fire. The nurse is assessing the extent of the burns using the Rule of Nines. What percentage of the total body surface area is assigned to the head and neck in adults?
a) 9%
b) 18%
c) 27%
d) 36%
e) 45%
Rationale: According to the Rule of Nines, the head and neck together constitute 9% of the total body surface area in adults. This method helps determine the extent of burns, guide fluid resuscitation, and plan care based on the percentage of body surface involved.
NCLEX Review: Burn Wounds
A 25-year-old patient sustains chemical burns on the forearm while working in a laboratory. The nurse initiates immediate first aid. What is the priority action for chemical burns?
a) Irrigate the affected area with copious amounts of water.
b) Apply a dry dressing over the burn.
c) Neutralize the chemical with an acidic solution.
d) Remove any clothing adhered to the burn.
e) Administer pain medication.
Rationale: The immediate priority for chemical burns is to remove the chemical by irrigating the affected area with copious amounts of water. This helps minimize tissue damage and prevent further injury. Applying dry dressing, neutralizing with acidic solutions, removing adhered clothing, and administering pain medication are secondary actions.
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A 30-year-old patient with second-degree burns on the chest is prescribed a topical antibiotic ointment. The nurse educates the patient on proper application. What instruction is essential for the patient?
a) Apply the ointment liberally and cover with an airtight dressing.
b) Cleanse the burn area with alcohol before applying the ointment.
c) Change the dressing and reapply the ointment every 48 hours.
d) Avoid exposing the burn to air by keeping it covered at all times.
e) Massage the ointment into the burn to enhance absorption.
Rationale: Changing the dressing and reapplying the ointment every 48 hours helps maintain a clean wound environment and prevents infection. Liberally applying ointment with an airtight dressing, cleansing with alcohol, constant covering, and massaging can impede the healing process or lead to complications.
NCLEX Focus: Exploring Burn Injuries
A 45-year-old patient sustains full-thickness burns on both lower extremities due to a workplace accident involving hot machinery. The nurse assesses the burns for signs of compartment syndrome. Which finding indicates the potential development of compartment syndrome?
a) Decreased pain on passive movement.
b) Capillary refill less than 3 seconds.
c) Warm and pink skin.
d) Swelling with increased pain on passive movement.
e) Numbness and tingling in the affected areas.
Rationale: Swelling with increased pain on passive movement is indicative of compartment syndrome, a potential complication of burns. Compartment syndrome occurs when increased pressure within a muscle compartment compromises blood flow. Other options, such as decreased pain, normal capillary refill, warm skin, and numbness/tingling, are not specific to compartment syndrome.
NCLEX Questions: Focus on Burn Injuries
A 50-year-old patient is receiving nutritional support after sustaining severe burns. The nurse monitors for signs of adequate nutritional intake. Which assessment finding suggests effective nutritional support for this patient?
a) Weight loss of 5 pounds.
b) Serum albumin level of 1.5 g/dL.
c) Hemoglobin level within the normal range.
d) Urine output of 200 mL per hour.
e) Improved wound healing.
Rationale: Improved wound healing is a positive indicator of effective nutritional support in burn patients. Weight loss, low serum albumin, normal hemoglobin, and increased urine output are not direct indicators of nutritional adequacy for burn patients.
A pediatric patient is brought to the emergency room with partial-thickness burns on the face. The nurse assesses the burns for potential complications. Which complication is associated with facial burns in pediatric patients?
a) Risk of hypothermia.
b) Risk of airway compromise.
c) Risk of compartment syndrome.
d) Risk of impaired mobility.
e) Risk of peripheral nerve damage.
Rationale: Facial burns in pediatric patients can lead to airway compromise due to the proximity of the burn site to the airway. Assessing and managing the airway is crucial to prevent complications. Hypothermia, compartment syndrome, impaired mobility, and peripheral nerve damage are not specifically associated with facial burns.
Understanding the Burn Injuries: NCLEX Delegation Questions
A 60-year-old patient with second-degree burns on the hands is prescribed a silver sulfadiazine cream. The nurse provides education on the use of this medication. What information is essential for the patient regarding silver sulfadiazine cream?
a) Apply the cream in a thick layer and cover with an occlusive dressing.
b) Use the cream only once a day to avoid overmedication.
c) Apply the cream and expose the hands to sunlight for enhanced effectiveness.
d) Cleanse the hands with alcohol before applying the cream.
e) Change the dressing every 12 hours to maintain a moist environment.
Rationale: Changing the dressing every 12 hours helps maintain a moist environment, promoting optimal wound healing with silver sulfadiazine cream. Applying a thick layer with an occlusive dressing, using the cream once a day, exposing to sunlight, and cleansing with alcohol are not recommended practices and may lead to complications.