Burns NCLEX Questions

Let’s dive in, answer questions on burn severity, how to manage burn pain, and prevent complications in burned patients.

Question A 45-year-old male is admitted with second-degree burns over 25% of his body, primarily on the chest and arms. Which of the following interventions should the nurse prioritize?
A) Administration of oral pain medication

B) Application of ice to burned areas

C) Initiation of intravenous fluids

D) Application of antibiotic ointment

E) Immediate physical therapy for burned areas
Rationale: Patients with significant burns, especially those covering more than 20% of the body, are at high risk for hypovolemic shock due to fluid loss from damaged capillaries. Initiating intravenous fluids is critical to prevent shock and ensure adequate circulation and tissue perfusion. Oral medications may not be absorbed effectively due to compromised circulation. Ice can cause further tissue damage and should be avoided, while antibiotic ointments and physical therapy are important but not immediate priorities compared to fluid resuscitation. Correct Answer: C) Initiation of intravenous fluids

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Question Which of the following is the most appropriate initial step in managing a patient who just sustained a thermal burn to the hand while cooking?
A) Apply butter to the burn area

B) Place the hand under cool running water

C) Cover the burn with a cotton bandage

D) Break any blisters that have formed

E) Apply a tourniquet above the burned area
Rationale: Immediate cooling of a thermal burn under cool running water helps stop the burning process, reduces pain, and minimizes edema and tissue damage. Applying butter or any other substance can introduce infection and is not recommended. Covering the burn with a bandage is appropriate after cooling, but not initially. Breaking blisters can also introduce infection and should be avoided. A tourniquet is not appropriate for a burn injury and can cause further damage. Correct Answer: B) Place the hand under cool running water

Question A patient with third-degree burns over 40% of their body is at increased risk for which of the following complications?
A) Hypoglycemia

B) Hypokalemia

C) Hypothermia

D) Hypercalcemia

E) Hypertension
Rationale: Patients with extensive burns lose the protective barrier of the skin, making them susceptible to heat loss and consequently hypothermia. The body’s thermoregulation is compromised, necessitating interventions to maintain body temperature. Hypoglycemia, hypokalemia, hypercalcemia, and hypertension may occur in burn patients but are not directly caused by the loss of skin integrity and the body’s inability to retain heat as hypothermia is. Correct Answer: C) Hypothermia

Question When planning care for a patient with burns on the lower extremities, which of the following goals is most appropriate?
A) Achieve full range of motion within 24 hours

B) Prevent infection in the burn areas

C) Ensure the patient walks independently by discharge

D) Apply heat to the burns every 2 hours

E) Perform debridement in the first 12 hours
Rationale: Infection prevention is a critical goal in the care of burn patients due to the increased risk of infection from the loss of skin integrity. Achieving full range of motion and walking independently are important rehabilitation goals but are secondary to preventing infection in the acute phase. Applying heat can cause additional tissue damage and is not recommended. Early debridement is important but must be carefully timed based on the patient’s condition and wound assessment. Correct Answer: B) Prevent infection in the burn areas

Question A nurse is educating a patient on home care after receiving a minor second-degree burn on the forearm. Which instruction is most important to include?
A) “Keep the burn exposed to air at all times.”

B) “Use ice directly on the burn to relieve pain.”

C) “Apply aloe vera gel three times daily.”

D) “Watch for signs of infection, such as increased redness, swelling, or pus.”

E) “Wrap the burn tightly with a bandage to prevent movement.”
Rationale: Monitoring for signs of infection is crucial in burn care to prevent complications. While keeping the burn clean and somewhat exposed can aid in healing, completely exposing it to air at all times is not necessary and may increase the risk of infection. Ice can cause further tissue damage and is not recommended. While aloe vera gel can soothe and have a mild antibacterial effect, preventing infection through careful monitoring is more important. Wrapping the burn too tightly can restrict circulation and is not advised. Correct Answer: D) Watch for signs of infection, such as increased redness, swelling, or pus.

Question For a patient with extensive burns receiving enteral nutrition, which of the following is a primary reason for this intervention?
A) To promote wound healing

B) To prevent renal failure

C) To enhance patient mobility

D) To reduce the risk of thrombosis

E) To manage pain more effectively
Rationale: Enteral nutrition provides the necessary calories, proteins, vitamins, and minerals that are crucial for the healing process of burn wounds. Adequate nutrition supports the body’s increased metabolic demands caused by the stress of injury and the need for tissue repair. While preventing renal failure, enhancing mobility, reducing the risk of thrombosis, and managing pain are important in burn care, they are not the primary reasons for initiating enteral nutrition, which is specifically targeted to meet the heightened nutritional needs for wound healing. Correct Answer: A) To promote wound healing

Question A nurse is caring for a patient with facial burns. Which of the following actions is most important to prevent airway compromise
A) Administering pain medication regularly

B) Keeping the head of the bed elevated

C) Applying moist dressings to the face

D) Encouraging coughing and deep breathing exercises

E) Monitoring oxygen saturation continuously
Rationale: Elevating the head of the bed helps to reduce facial and airway edema in patients with facial burns, which can prevent airway compromise. While administering pain medication is important for comfort, and moist dressings can aid in healing, neither directly prevents airway compromise like elevation does. Coughing and deep breathing exercises are important for lung health but are secondary to physical measures that decrease swelling. Continuous oxygen saturation monitoring is critical for detecting hypoxia but does not actively prevent airway compromise. Correct Answer: B) Keeping the head of the bed elevated

Question In the acute phase of burn treatment, which of the following is a key indicator of adequate fluid resuscitation?
A) Decreased heart rate

B) Increased urine output

C) Reduced pain level

D) Increased body temperature

E) Decreased blood pressure
Rationale: Increased urine output is a key indicator of adequate fluid resuscitation in the acute phase of burn treatment. It reflects effective circulation and kidney function, suggesting that tissues are receiving sufficient perfusion. A decreased heart rate might indirectly reflect volume resuscitation but is not as specific as urine output. Reduced pain level and increased body temperature are not direct indicators of fluid resuscitation effectiveness. Adequate resuscitation typically stabilizes or increases blood pressure, not decreases it, making increased urine output the best indicator among the options provided. Correct Answer: B) Increased urine output

Question Which of the following strategies is most effective in reducing the psychological impact of disfigurement in a patient with severe facial burns?
A) Immediate surgical intervention

B) Regular administration of analgesics

C) Participation in burn survivor support groups

D) Application of cosmetic makeup

E) Frequent reassurance about appearance
Rationale: Participation in burn survivor support groups is highly effective in reducing the psychological impact of disfigurement by providing emotional support, sharing coping strategies, and creating a sense of community among individuals with similar experiences. Immediate surgical intervention and the application of cosmetic makeup may improve physical appearance but do not address the underlying psychological impact. Regular administration of analgesics helps manage pain but not the psychological aspects of disfigurement. While frequent reassurance about appearance can be supportive, it does not offer the same level of shared experience and understanding as participation in support groups. Correct Answer: C) Participation in burn survivor support group

Question A burn patient is undergoing skin grafting. Which of the following is crucial for the nurse to monitor in the post-operative period?
A) Graft adherence to the wound bed

B) Maximum range of motion

C) Nutritional intake

D) Cognitive function

E) Social interactions
Rationale: Monitoring graft adherence to the wound bed is crucial in the post-operative period for a patient undergoing skin grafting. Successful grafting requires the graft to integrate with the underlying tissue, which is critical for healing and preventing infection or graft failure. While nutritional intake is important for healing, cognitive function for overall health, and social interactions for psychological well-being, these do not directly impact the immediate success of the skin graft like ensuring graft adherence does. Ensuring maximum range of motion is a rehabilitation goal post-healing and not as immediate a concern as graft adherence. Correct Answer: A) Graft adherence to the wound bed

Nursing diagnosis for burns

As you write your nursing care plan for burns, focus on your assessment, diagnosis, goals, and outcomes. As you do this, determine your nursing interventions going forward. Finally, evaluate your plan and make sure it is appropriate for your patient. If you know the anatomy of the skin, you can understand how to determine burn depth and the appropriate treatment options. Remember, you are also looking for other obvious and occult injuries to other systems.

Nurse Care Plan for Burns – Assessment

How are burns described?  

Describe the burn using the following Burn Wound Classification:   

1st degree:   

The burn involves the epidermis only, a “sunburn”  

CHARACTERISTICS:

• Erythema (redness)

• Dry

• Painful  

• Healing: 3-6 Days 

2nd degree (partial thickness):

The burn extends into dermis   

The dermis is vascular. Capillaries, when damaged and exposed to local inflammatory mediators, “leak” fluid, this lifts the overlying epidermis and forms a blister or bullae.  

CHARACTERISTICS:

• Pink or Red but moist instead of dry

• Painful

• Blisters and bullae are moist or weeping

• Healing: 10-21 Days  

3rd degree (full thickness): 

The burn extends into hypodermis or subcutaneous layer

CHARACTERISTICS:

• Dry  

• Thrombosed vessels may be seen

• Insensate

• The burn is white (often described as parchment paper)

• Requires Grafting 

The characteristics of the burn wound are so typical that even if you can’t clearly determine the depth (degree) of the burn is, most surgeons will ask you very specific questions about what you see. In doing so, they will know what depth of burn you are dealing with.  Don’t worry too much about being exact when determining burn depth, DO concern yourself with accurately describing what you see.  Why? Determining depth (and need for surgery) within the 1st 24h of a burn is very difficult in some cases.  One reason for this is that burns “declare” themselves.  This may be due to progressive microvessel thrombosis, perfusion and to some degree the adequacy of resuscitation.  The key at your initial assessment is to describe what you see, realize your assessment may change and be ready to alter your treatment plan accordingly. 

Perform Burn Wound Care, Initial Care A.S.A.P.

• Cleanse the wound (ideally with CHG)

• Trim loose, nonviable skin 

• Reassess the burn wound and do a burn wound diagram to include burn and donors available. After a thorough cleansing the %TBSA and the depth of the wounds may appear quite different.  The assessment is much more accurate at this point.

• Apply a topical agent of choice CHG

• Use chorohexidine gluconate soap to wash away dirt and debris.  This agent has antimicrobial activity against most skin flora  

Why use topical agents? 

The principle:  Prophalaxis – prevent burn wound infection  

• Lower burn wound colonization

• Reduces burn wound infection

• Lowers burn wound sepsis

• Improves survival  

• Is considered standard of care   

The common topical agents are: 

 Sulfamylon 

• 11.1% cream or 5% solution 

• Bacteriostatic. 

Good gram positive and gram negative coverage, including pseudomonas but not very effective against fungi    

• Soluble 

• Diffuses through eschar (penetrates)   

 Systemically absorbed     

• The cream is applied 1/8 inch thick, every 12 hours or alternating with silvadene every 12 hours to limit metabolic acidosis     

• The 5% solution is applied as a wetsoak and requires reapplication every 4 to 6 hours to prevent the dressing from drying resulting in dessication of the wound

• Probably the BEST agent for full thickness burns

Limitations:  

• Pain when applied to partial thickness (PT) burns.  

• Inhibition of carbonic anhydrase results in bicarbonate loss, metabolic acidosis and hyperventilation.  This can be limited by alternating every 12 hours with silvadene.  

• Acidic wound environment with prolonged use favors candida colonization. 

• Believed to retard wound healing (a relative limitation, often the benefits of this drug outweigh this).   

Silvadene

• 1% suspension cream 

• Bacteriostatic, effective against pseudomonas 

• Some anti-candidal activity • Limited diffusion (penetration), poor penetration of eschar 

• No pain • Applied 1/8 inch thick, every 12 hours or alternating with sulfamylon every 12 hrs. 

• VERY GOOD for partial thickness burns.  

• Use it for full thickness burn if you don’t have sulfamylon but know that it is suboptimal  

• Can be used with nystatin 

• Useful to alternate every 12 hours with sulfamylon to limit sulfamylon induced metabolic acidosis  

Limitations:       

• Neutropenia       

• Not effective against some strains of Pseudomonas and Enterobacter cloacae       

• Some reports of resistance against pseudomonas       

• Retards wound healing (relative limitation) 

Silver Nitrate 

• 0.5% solution 

• Most agree therapeutic efficacy is similar to silvadene but is more inconvenient to use 

• Applied as many layered soaks, moistened every two hours, changed 2-3x’s per day 

• No pain 

• No penetration 

• Useful in TENS 

• Useful in patients allergic to sulfa drugs 

Limitations:  

• Leaches sodium, potassium, calcium and chloride leading to ‘hypo-deficits’ 

• Liquid may be absorbed leading to ‘water loading’ 

• High maintenance, stains linens, skin  

• May cause methemoglobinemia 

Acticoat

• Has broad antimicrobial activity including MRSA

• Effective against candida  

• Sheet of thin polyester and polyethylene mesh impregnated with silver

• When wet (i.e. exposed to body fluids) or moistened with

 sterile water, silver ions are released

• Wetdown is done every 6 hours (q6Hrs)

• Each sheet last 48-72 hrs.

• Change the sheet if it looks soiled or is malodorous  

Limitation: cost  

Sodium Hypoclorite

• Very broad antimicrobial activity

• Bactericidal against gram positive and gram negative organisms pseudomonas

• Useful in what appears to be overwhelming pseudomonas wound colonization, used as a wetsoak moistened every 6 hours 

Limitation: At higher concentrations may be toxic to fibroblast and inhibit epithelialization

Nystatin

• Binds to sterols (in the membrane of fungi)

• Fungicidal and fungal static  

Limitation:  Not effective against organisms that do not have sterols in their membrane (i.e. viruses and bacteria)  

Bactroban

• Effective against gram positive including MRSA, limited efficacy against gram negative organisms

• Useful in the outpatient setting to treat limited infections, often applied TID  

Limitations: 

• Superinfection (when used for a prolonged period) 

• Not for use on very large wounds with high absorption because ointment contains polyethylene glycol  

Bacitracin

• Not effective in controlling wound infection

• Used often as an ointment to cover skin grafts to prevent drying

• Active against some bacteria  

Limitations: Dermatitis has been reported Superinfection (when used for a prolonged period)  

These are just some examples; newer agents and modalities are being made to improve outcomes and survival.

PEARL:   One of the reasons for not putting antimicrobial creams on a patient with partial thickness burns early is that it may not allow for placement of some biologic dressings once the patient gets to a specialized burn center. Placing antimicrobial creams was, until recently, a practice done in most emergency rooms before transport.   The appropriate use of biological dressings can save patients from prolonged initial hospitalization AND daily dressing changes.  If placed within 12-24 hours of arrival at a burn center patients often go home the next day.  CAVEAT: If patients will have to remain without a topical antimicrobial for 6 hours or more (i.e. if transport is delayed), it is reasonable and prudent to apply an antimicrobial cream, especially in larger partial thickness burns.  If you are transporting a patient a long distance perhaps with a layover (i.e. greater than 12-24 hours), remember that the effectiveness of the creams is nil after 12 hours. Therefore, one must insist that reapplication is done on schedule (q 12 hours). Otherwise, the patient is essentially without antimicrobial coverage and is at risk for infection. 

What’s next? …establish skin graft priorities.  

Skin Graft Priorities

• Survival:  close the wound       

• Function:  hands, feet, joints  

Why is this important?  This is very important if you have patient with a large TBSA burn. Ideally, you want to get as much burn (which is nonviable tissue and is a great medium for bacterial and fungal growth) excised as soon as possible. 

Think Long Term:  If your wound does not heal in 14 days, the risk of contracture, poor cosmetic outcome, and suboptimal skin (thin, fragile, easily broken) is high. For that reason, excision and skin grafting at that time is recommended.  Dermal Wound Healing >14 Days = High risk for scarring and contractures.  

If the patient will not tolerate a long operation, consider just excising the burn and placing allograft (this is fast and there is less blood loss because you are not harvesting skin).   If you cannot use a multi-surgical team approach, in lieu of excising and autografting the hands (which takes more time, Is preferably sheet graft and requires more skin per unit area), consider doing the hands at a later date. Many now believe that with a good aggressive OT/PT team the functional outcome is unchanged with late grafting of the hands.  If you don’t have enough of the patient’s skin available for autografting, use allograft, xenograft or an alternate skin substitute to cover the wound (reducing water loss and metabolic demand). This is important in the elderly and in large burns. Remember, it is said that prolonged SIRS is like running a marathon in terms of metabolic and cardiac demand. Most 70-year-olds aren’t accustomed to running marathons. Even the young and healthy tire over time.  Ideally, you should get the entire burn off in 7 to 10 days. Cover the wound with autograft or a suitable substitute.  

Excision and Grafting Surgery Intraoperative Approach:

It may be safer to stop when: You have completed 20-30% excision

Operating time is >2 hours (in some institutions 2-4 hrs.) 

There is 1 blood volume blood loss 

There is unresponsive hypothermia or acidosis  

The patient is having repeated episodes of hypotension

In Summary    

        Burn injuries can result in devastating consequences for patients and their families. As a nurse, it is essential to develop an effective nursing care plan that can provide comprehensive and individualized care for burn patients. Burn injuries are classified based on their depth, extent of tissue damage, and total body surface area affected. Nursing care plans for burn patients must address the immediate and long-term needs of the patient.

        The initial nursing diagnosis for burn patients should focus on monitoring vital signs, assessing airway patency, and fluid resuscitation. Patients with burns over a large body surface area may require fluid resuscitation to maintain adequate tissue perfusion and prevent hypovolemic shock. The rule of nines is used to estimate the extent of burn injury, which is critical in determining fluid replacement needs. The nurse must also assess the patient’s respiratory rate, breath sounds, and signs of smoke inhalation or carbon monoxide poisoning. Pain management is an essential part of the nursing care plan for burn patients. Burns can cause severe pain due to the destruction of nerve endings. The nurse must evaluate the patient’s pain level and administer pain medication as needed. The nurse can also use non-pharmacological pain management techniques such as relaxation exercises, distraction techniques, and positioning.

        Wound care is a crucial component of the nursing care plan for burn patients. The nurse must assess the burn wound’s depth and extent and monitor for signs of infection. Superficial partial-thickness burns typically heal within a few weeks and do not require skin grafting. However, deep partial-thickness and full-thickness burns may require skin grafting, which the nurse must monitor for complications such as delayed healing, rejection, or infection. Physical mobility is related burn wound care. burn edema and burn wound healing impaired mobility and range of motion (ROM). Burn injuries can cause contractures, tissue damage, and scarring that can limit movement. Nurses should assess the patient’s physical mobility and develop a plan to prevent contractures, maintain range of motion, and encourage mobility.

        The nursing care plan should include interventions to prevent the risk of infection. Burn wounds are vulnerable to infection due to the loss of skin integrity and exposure to the environment. The nurse should use sterile techniques during wound care, monitor for signs of infection, and administer prophylactic antibiotics as needed. Nursing care plans for burn patients should address other patient needs such as body image, nutrition, and psychosocial support. Burn injuries can cause significant changes in a patient’s appearance, leading to emotional distress. The nurse can provide education and support to the patient and family to cope with these changes. Nutritional support is essential for wound healing and tissue repair, and the nurse should monitor the patient’s fluid volume, body temperature, and urinary output. Nursing care plans for burn patients should be comprehensive, individualized, and address the immediate and long-term needs of the patient. The nurse must assess the patient’s body surface area, depth of burn, and signs and symptoms of inhalation injuries. The nursing diagnosis should include monitoring vital signs, fluid resuscitation, pain management, wound care, risk of infection, and impaired physical mobility. The nursing care plan should also address patient needs such as body image, nutrition, and psychosocial support. With effective nursing care, burn patients can achieve desired outcomes, such as wound healing, pain relief, and improved quality of life.

        Nursing care plans for patients with burn injuries must address a range of issues, including fluid volume deficit, impaired physical mobility, pain management, airway clearance, and wound care procedures. Care plans should be tailored to the extent and depth of the burn, and should involve regular dressing changes to prevent eschar formation and promote wound healing. Occupational therapy may also be beneficial for individuals with burn injuries, helping to promote independence in self-care and improve overall quality of life. Pulmonary artery wedge pressures and monitoring serum electrolyte levels may also be necessary in cases of inhalation injuries or extensive burns.

        Burn injuries can result in significant tissue destruction and may affect individuals of all age groups. Burn injuries may be caused by a variety of factors, including heat sources such as flames, scalding liquids, and hot surfaces, as well as motor vehicle crashes and chemical exposure. Self-care and nursing intervention are critical components of managing burn injuries and achieving the desired outcomes. The extent of the burn injury is commonly assessed by calculating the body surface area affected, using the “rule of nines.” This helps to determine the appropriate level of care needed, such as monitoring vital signs and airway patency. The depth of the burn is also assessed, with partial thickness burns involving the epidermis and dermis, and full thickness burns destroying the entire skin layer, including nerve endings.

        Infection control is a critical component of burn treatment, with proper hygiene practices and isolation precautions to prevent the spread of infection. The burn team, which may include physicians, nurses, and other healthcare professionals, work together to manage the patient’s care plan and adjust interventions as necessary to achieve the desired outcomes. Nursing interventions and self-care are critical for managing burn injuries, and care plans should be tailored to the extent and depth of the burn. Burn treatment may also involve occupational therapy and monitoring of pulmonary artery wedge pressures and serum electrolyte levels, along with infection control measures to prevent the spread of infection. By working together, the burn team can help patients achieve optimal outcomes and promote overall well-being.