1b|bP a g e
NUR 221 EXAM 3 ACTUAL EXAM VERSION 1,2,3&4
b b b b b b b b
WITH ALL QUESTIONS AND CORRECT ANSWERS A b b b b b b
LREADY GRADED A+||LATEST AND COMPLETE UP b b b b b
DATE 2024 WITH 100% VERIFIED SOLUTIONS|| ASSb b b b b b
URED PASS b b
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen,
b b b b b b b b b b b b b b b b
decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the
b b b b b b b b b b b
nurse anticipates interventions to evaluate and treat the patient for what complication
b b b b b b b b b b b
?
A. Acute kidney injury
b b b
B. Acute respiratory distress syndrome
b b b b
C. Intraabdominal hypertension
b b
D. Disseminated intravascular coagulation disorder -
b b b b b
ANSWER: C. Intraabdominal hypertension
b b b b
An elderly individual from an assisted living facility (ALF) presents with severe scal
b b b b b b b b b b b b
d burns to the buttocks and back of the thighs. The caregiver from the ALF accompan
b b b b b b b b b b b b b b b
ies the patient to the emergency department and states that the bath water was "too ho
b b b b b b b b b b b b b b b
t" and that the "patient sat in the water too long." What should the nurse do to best ach
b b b b b b b b b b b b b b b b b b
ieve an accurate history of the event?
b b b b b b
A. Ask the caregiver at what temperature the water heater is set in the home.
b b b b b b b b b b b b b b
B. Ask the caregiver to step out while examining the patient's burn injury.
b b b b b b b b b b b b
C. Immediately contact the police to report the suspected elder abuse.
b b b b b b b b b b
,2b|bP a g e
D. Ask the caregiver to describe exactly how the injury occurred. -
b b b b b b b b b b b
ANSWER: B. Ask the caregiver to step out while examining the patient's burn injur
b b b b b b b b b b b b b b
y
Why is silver is used as an ingredient in many burn dressings?
b b b b b b b b b b b
A. Stimulates tissue granulation.
b b b
B. Is effective against a wide spectrum of wound pathogens.
b b b b b b b b b
C. Provides topical pain relief.
b b b b
D. Stimulates wound healing. -
b b b b
ANSWER: B. Is effective against a wide spectrum of wound pathogens
b b b b b b b b b b b
The nurse understands that negative pressure wound therapy may be used in the treat
b b b b b b b b b b b b b
ment of partial-thickness burn wounds to accomplish what outcome?
b b b b b b b b
A. Maintain a closed wound system to decrease the risk of infection.
b b b b b b b b b b b
B. Remove excessive wound fluid and promote moist wound healing.
b b b b b b b b b
C. Increase patient mobility with large burn wounds.
b b b b b b b
D. Quantify wound drainage amount for more accurate output assessment. -
b b b b b b b b b b
ANSWER: B. Remove excessive wound fluid and promote moist wound healing.
b b b b b b b b b b b
The nurse caring for a patient with an electrical injury understands that patients with
b b b b b b b b b b b b b b
electrical injury are at a high risk for acute kidney injury secondary to what related pr
b b b b b b b b b b b b b b b
ocess?
,3b|bP a g e
A. Hypervolemia from burn resuscitation
b b b b
B. Increased incidence of ureteral stones
b b b b b
C. Nephrotoxic antibiotics for prevention of infection
b b b b b b
D. Release of myoglobin from injured tissues -
b b b b b b b
ANSWER: D. Release of myoglobin from injured tissues
b b b b b b b b
What is the priority nursing intervention for a patient who experienced a chemical bu
b b b b b b b b b b b b b
rn injury?
b
A. Remove the patient's clothes and flush the area with water.
b b b b b b b b b b
B. Apply saline compresses.
b b b
C. Contact a poison control center for directions on neutralizing agents.
b b b b b b b b b b
D. Remove all jewelry. -
b b b b
ANSWER: A. Remove the patient's clothes and flush the area with water.
b b b b b b b b b b b b
What is the most likely site to have a sheet graft applied?
b b b b b b b b b b b
A. Arm
b
B. Face
b
C. Leg
b
D. Chest - ANSWER: B. Face
b b b b b
The nurse is caring for a patient who has undergone skin grafting of the face and arms
b b b b b b b b b b b b b b b b
for burn wound treatment. What is a primary nursing diagnosis for this patient?
b b b b b b b b b b b b b
, 4b|bP a g e
A. Altered nutrition, less than body requirements
b b b b b b
B. Body image disturbance
b b b
C. Decreased cardiac output
b b b
D. Fluid volume deficit - ANSWER: B. Body image disturbance
b b b b b b b b b
The nurse is assisting the patient who is recovering from moderate burns to select foo
b b b b b b b b b b b b b b
ds from the menu that will promote wound healing. Which statement indicates the nu
b b b b b b b b b b b b b
rse's knowledge of nutritional goals?
b b b b
A. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wo
b b b b b b b b b b b b b b b
und to heal." b b
B. "Choose foods that are high in protein, such as meat, eggs, and beans. These help t
b b b b b b b b b b b b b b b b
he burns to heal."
b b b
C. "It is important to choose foods like bread and pasta that are high in carbohydrates.
b b b b b b b b b b b b b b b
These foods will give you energy and help you to heal faster."
b b b b b b b b b b b b
D. "Select foods that have lots of fiber, such as whole grains and fruits. These will pro
b b b b b b b b b b b b b b b b
mote removal of toxins from the body that interfere with healing." -
b b b b b b b b b b b
ANSWER: B. "Choose foods that are high in protein, such as meat, eggs, and beans.
b b b b b b b b b b b b b b b
These help the burns to heal."
b b b b b b
A burn patient in the rehabilitation phase of injury is increasingly anxious and unable
b b b b b b b b b b b b b b
to sleep. The nurse should consult with the provider to further assess the patient for w
b b b b b b b b b b b b b b b
hat possible mental health condition?
b b b b
A. Acute delirium
b b
B. Posttraumatic stress disorder
b b b
C. Suicidal intentions
b b
NUR 221 EXAM 3 ACTUAL EXAM VERSION 1,2,3&4
b b b b b b b b
WITH ALL QUESTIONS AND CORRECT ANSWERS A b b b b b b
LREADY GRADED A+||LATEST AND COMPLETE UP b b b b b
DATE 2024 WITH 100% VERIFIED SOLUTIONS|| ASSb b b b b b
URED PASS b b
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen,
b b b b b b b b b b b b b b b b
decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the
b b b b b b b b b b b
nurse anticipates interventions to evaluate and treat the patient for what complication
b b b b b b b b b b b
?
A. Acute kidney injury
b b b
B. Acute respiratory distress syndrome
b b b b
C. Intraabdominal hypertension
b b
D. Disseminated intravascular coagulation disorder -
b b b b b
ANSWER: C. Intraabdominal hypertension
b b b b
An elderly individual from an assisted living facility (ALF) presents with severe scal
b b b b b b b b b b b b
d burns to the buttocks and back of the thighs. The caregiver from the ALF accompan
b b b b b b b b b b b b b b b
ies the patient to the emergency department and states that the bath water was "too ho
b b b b b b b b b b b b b b b
t" and that the "patient sat in the water too long." What should the nurse do to best ach
b b b b b b b b b b b b b b b b b b
ieve an accurate history of the event?
b b b b b b
A. Ask the caregiver at what temperature the water heater is set in the home.
b b b b b b b b b b b b b b
B. Ask the caregiver to step out while examining the patient's burn injury.
b b b b b b b b b b b b
C. Immediately contact the police to report the suspected elder abuse.
b b b b b b b b b b
,2b|bP a g e
D. Ask the caregiver to describe exactly how the injury occurred. -
b b b b b b b b b b b
ANSWER: B. Ask the caregiver to step out while examining the patient's burn injur
b b b b b b b b b b b b b b
y
Why is silver is used as an ingredient in many burn dressings?
b b b b b b b b b b b
A. Stimulates tissue granulation.
b b b
B. Is effective against a wide spectrum of wound pathogens.
b b b b b b b b b
C. Provides topical pain relief.
b b b b
D. Stimulates wound healing. -
b b b b
ANSWER: B. Is effective against a wide spectrum of wound pathogens
b b b b b b b b b b b
The nurse understands that negative pressure wound therapy may be used in the treat
b b b b b b b b b b b b b
ment of partial-thickness burn wounds to accomplish what outcome?
b b b b b b b b
A. Maintain a closed wound system to decrease the risk of infection.
b b b b b b b b b b b
B. Remove excessive wound fluid and promote moist wound healing.
b b b b b b b b b
C. Increase patient mobility with large burn wounds.
b b b b b b b
D. Quantify wound drainage amount for more accurate output assessment. -
b b b b b b b b b b
ANSWER: B. Remove excessive wound fluid and promote moist wound healing.
b b b b b b b b b b b
The nurse caring for a patient with an electrical injury understands that patients with
b b b b b b b b b b b b b b
electrical injury are at a high risk for acute kidney injury secondary to what related pr
b b b b b b b b b b b b b b b
ocess?
,3b|bP a g e
A. Hypervolemia from burn resuscitation
b b b b
B. Increased incidence of ureteral stones
b b b b b
C. Nephrotoxic antibiotics for prevention of infection
b b b b b b
D. Release of myoglobin from injured tissues -
b b b b b b b
ANSWER: D. Release of myoglobin from injured tissues
b b b b b b b b
What is the priority nursing intervention for a patient who experienced a chemical bu
b b b b b b b b b b b b b
rn injury?
b
A. Remove the patient's clothes and flush the area with water.
b b b b b b b b b b
B. Apply saline compresses.
b b b
C. Contact a poison control center for directions on neutralizing agents.
b b b b b b b b b b
D. Remove all jewelry. -
b b b b
ANSWER: A. Remove the patient's clothes and flush the area with water.
b b b b b b b b b b b b
What is the most likely site to have a sheet graft applied?
b b b b b b b b b b b
A. Arm
b
B. Face
b
C. Leg
b
D. Chest - ANSWER: B. Face
b b b b b
The nurse is caring for a patient who has undergone skin grafting of the face and arms
b b b b b b b b b b b b b b b b
for burn wound treatment. What is a primary nursing diagnosis for this patient?
b b b b b b b b b b b b b
, 4b|bP a g e
A. Altered nutrition, less than body requirements
b b b b b b
B. Body image disturbance
b b b
C. Decreased cardiac output
b b b
D. Fluid volume deficit - ANSWER: B. Body image disturbance
b b b b b b b b b
The nurse is assisting the patient who is recovering from moderate burns to select foo
b b b b b b b b b b b b b b
ds from the menu that will promote wound healing. Which statement indicates the nu
b b b b b b b b b b b b b
rse's knowledge of nutritional goals?
b b b b
A. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wo
b b b b b b b b b b b b b b b
und to heal." b b
B. "Choose foods that are high in protein, such as meat, eggs, and beans. These help t
b b b b b b b b b b b b b b b b
he burns to heal."
b b b
C. "It is important to choose foods like bread and pasta that are high in carbohydrates.
b b b b b b b b b b b b b b b
These foods will give you energy and help you to heal faster."
b b b b b b b b b b b b
D. "Select foods that have lots of fiber, such as whole grains and fruits. These will pro
b b b b b b b b b b b b b b b b
mote removal of toxins from the body that interfere with healing." -
b b b b b b b b b b b
ANSWER: B. "Choose foods that are high in protein, such as meat, eggs, and beans.
b b b b b b b b b b b b b b b
These help the burns to heal."
b b b b b b
A burn patient in the rehabilitation phase of injury is increasingly anxious and unable
b b b b b b b b b b b b b b
to sleep. The nurse should consult with the provider to further assess the patient for w
b b b b b b b b b b b b b b b
hat possible mental health condition?
b b b b
A. Acute delirium
b b
B. Posttraumatic stress disorder
b b b
C. Suicidal intentions
b b