TISSUE INTEGRITY - NCLEX QUESTIONS
A client who has had a full-thickness burn is being discharged from the hospital. Which information is
most important for the nurse to provide prior to discharge?
1. How to maintain home smoke detectors
2. Joining a community reintegration program
3. Learning to perform dressing changes
4. Options available for scar removal
3. Learning to perform dressing changes
Explanation:
Critical for the goal of progression toward independence for the client is teaching clients and
family members to perform care tasks such as dressing changes. All the other distractors are
important in the rehabilitation stage. However, dressing changes have priority.
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40;
heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal
pulses. Which action will the nurse take first?
1. Begin intravenous fluids
2. Check the pulses with a Doppler device
3. Obtain a complete blood count (CBC)
4. Obtain an electrocardiogram (ECG)
1. Begin intravenous fluids
Explanation:
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious
injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or
bleeding problem is causing these vital signs. However these are not actions that the nurse
would take immediately. Checking pulses would indicate perfusion to the periphery but this is
not an immediate nursing action.
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several
hours later, the wheezing is no longer heard. What is the nurse's next action?
1. Documenting the findings
2. Loosening any dressings on the chest
3. Raising the head of the bed
4. Preparing for intubation
4. Preparing for intubation
, Explanation:
Clients with severe inhalation injuries may sustain such progressive obstruction that they may
lose effective movement of air. When this occurs, wheezing is no longer heard and neither are
breath sounds. The client requires the establishment of an emergency airway. The swelling
usually precludes intubation.
The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is
very painful. How will the nurse categorize this injury?
1. Full-thickness
2. Partial-thickness superficial
3. Partial-thickness deep
4. Superficial
2. Partial-thickness superficial
Explanation:
The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color
that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and
superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness
burns are red to white in color.
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are
present, and there is just a "small amount of pain." How will the nurse categorize this injury?
1. Full-thickness
2. Partial-thickness superficial
3. Partial-thickness deep
4. Superficial
1. Full-thickness.
Explanation:
The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown,
yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness
superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white
in color with pain, and superficial burn color is pink to red, with pain.
The client has experienced an electrical injury of the lower extremities. Which are the priority
assessment data to obtain from this client?
1. Current range of motion in all extremities
2. Heart rate and rhythm
3. Respiratory rate and pulse oximetry reading
4. Orientation to time, place, and person
A client who has had a full-thickness burn is being discharged from the hospital. Which information is
most important for the nurse to provide prior to discharge?
1. How to maintain home smoke detectors
2. Joining a community reintegration program
3. Learning to perform dressing changes
4. Options available for scar removal
3. Learning to perform dressing changes
Explanation:
Critical for the goal of progression toward independence for the client is teaching clients and
family members to perform care tasks such as dressing changes. All the other distractors are
important in the rehabilitation stage. However, dressing changes have priority.
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40;
heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal
pulses. Which action will the nurse take first?
1. Begin intravenous fluids
2. Check the pulses with a Doppler device
3. Obtain a complete blood count (CBC)
4. Obtain an electrocardiogram (ECG)
1. Begin intravenous fluids
Explanation:
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious
injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or
bleeding problem is causing these vital signs. However these are not actions that the nurse
would take immediately. Checking pulses would indicate perfusion to the periphery but this is
not an immediate nursing action.
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several
hours later, the wheezing is no longer heard. What is the nurse's next action?
1. Documenting the findings
2. Loosening any dressings on the chest
3. Raising the head of the bed
4. Preparing for intubation
4. Preparing for intubation
, Explanation:
Clients with severe inhalation injuries may sustain such progressive obstruction that they may
lose effective movement of air. When this occurs, wheezing is no longer heard and neither are
breath sounds. The client requires the establishment of an emergency airway. The swelling
usually precludes intubation.
The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is
very painful. How will the nurse categorize this injury?
1. Full-thickness
2. Partial-thickness superficial
3. Partial-thickness deep
4. Superficial
2. Partial-thickness superficial
Explanation:
The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color
that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and
superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness
burns are red to white in color.
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are
present, and there is just a "small amount of pain." How will the nurse categorize this injury?
1. Full-thickness
2. Partial-thickness superficial
3. Partial-thickness deep
4. Superficial
1. Full-thickness.
Explanation:
The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown,
yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness
superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white
in color with pain, and superficial burn color is pink to red, with pain.
The client has experienced an electrical injury of the lower extremities. Which are the priority
assessment data to obtain from this client?
1. Current range of motion in all extremities
2. Heart rate and rhythm
3. Respiratory rate and pulse oximetry reading
4. Orientation to time, place, and person
