NUR445 Exam 4 UPDATED Exam
Questions and CORRECT Answers
Superficial burns- Minimal damage to the epidermis, - CORRECT ANSWER -Dry, no
blisters; pink or red; blanches easily, Hypersensitive. 3-7 days with no scarring
Superficial partial-thickness burns- Entire epidermis and minimal damage to the dermis, -
CORRECT ANSWER -Blisters that may be closed or open and weeping; pink or red; mild
edema; blanches easily, Hypersensitive. 7-14 days with no scarring
Deep partial-thickness burns- Entire epidermis and deeper layers of the dermis, - CORRECT
ANSWER -Blisters that may be closed or open; waxy appearance; cherry red, mottled, or
pale in the center; edema; sluggish or no blanching, Hypersensitive around the wound edges but
may be sensitive to pressure only in the center. Healing may take 3-6 weeks and may leave some
scarring, or the wound may have to be surgically excised and grafted.
Full-thickness burns - Destruction of entire epidermis and dermis; may involve subcutaneous fat,
muscle, and/or bone, - CORRECT ANSWER -Dry, leathery; pale, white, brown, tan,
black, charred; no blanching; may be contracted if muscle involvement, No pain in the center of
the wound but may be sensitive to pressure. Will not heal without surgical excision and grafting
Fluid and Electrolyte Changes in the Emergent Phase - CORRECT ANSWER -
Generalized dehydration, Reduction in blood volume, Decreased urinary output, Hyperkalemia,
Hyponatremia, Metabolic acidosis, Elevated hematocrit
Fluid shift or capillary leak syndrome is a continuous leak of plasma from the vascular space into
the interstitial space. This is - CORRECT ANSWER -third spacing. Because of third
spacing, Excess weight gain occurs in the first 12 hours after a burn and can continue for 24-36
hours.
In burn clients, especially those involved in explosions or fires, inhalation injuries are a
significant concern. The airway must be - CORRECT ANSWER -assessed first to ensure it
is patent, and high-flow oxygen is administered to increase oxygen saturation and prevent
hypoxia.
,Facial burns, hoarseness, and singed nasal hairs suggest inhalation injury, which can lead to -
CORRECT ANSWER -rapid airway swelling. Early intubation is critical before the airway
becomes obstructed. Pain control and fluid resuscitation are also important but are not the first
priority in this scenario.
a patient has sustained a full-thickness burn to the entire chest and partial thickness burn to the
entire right arm. What is the TBSA?- - CORRECT ANSWER -45% (The full thickness
burns on the chest and abdomen account for 36% of the TBSA, as each of these areas is assigned
18% (9% for the front of the chest and 9% for the front of the abdomen). The partial thickness
burns on the entire right arm account for 9% of the TBSA. By adding 36% for the chest and
abdomen with 9% for the right arm, the total TBSA burn estimate is 45%.)
A client that has full thickness burns of the entire chest, and partial thickness burns of the entire
right arm. According to the rule of 9s, the entire chest is worth 18% while the entire arm is worth
9%. Therefore, the total body surface area burned is - CORRECT ANSWER -27%.
calculate the TBSA of a person who has sustained full-thickness burns to the poster head and
poster left arm - CORRECT ANSWER -9%.
Priority nursing intervention for partial thickness and full thickness burns - CORRECT
ANSWER -initiate a large-bore IV and infusion of 0.9% sodium chloride or Lactated
Ringer's.
In burn clients, especially those with burns covering a significant percentage of total body
surface area, fluid loss is a major concern due to increased capillary permeability and subsequent
third spacing. Adequate urine output—typically at least 30 to 50 mL/hr—and stable blood
pressure are key indicators that - CORRECT ANSWER -perfusion and renal function are
being maintained. In contrast, low urine output, delayed capillary refill, tachycardia, or signs of
fluid overload such as crackles in the lungs suggest inadequate or excessive fluid resuscitation
and require immediate reassessment of the treatment plan.
In major burn injuries, especially with deep full thickness burns, there is a significant risk of
fluid shifts due to the loss of integrity in the skin, leading to fluid and electrolyte imbalances.
Fluid resuscitation is crucial in the first 24-48 hours to prevent - CORRECT ANSWER -
, hypovolemic shock, stabilize blood pressure, and support organ function. The large bore IV
ensures that fluids can be administered quickly and efficiently. While pain management,
diuretics, and monitoring of intake and output are important aspects of care, fluid resuscitation is
the highest priority in the immediate post-burn period to address the risk of shock and organ
failure.
During the Emergent phase patients may experience delirium and fluctuating attention and
awareness. Educating the family and involving them in the client's care can - CORRECT
ANSWER -provide comfort and reduce anxiety, which may help prevent or mitigate
delirium. Family support is a critical element in managing delirium, as it can decrease confusion
and provide reassurance.
During the intermediate phase of burn recovery, the nurse should focus on wound infection, as
the loss of skin's protective barrier increases the risk for - CORRECT ANSWER -bacterial
invasion. Nutritional deficiencies are a concern due to the hypermetabolic state of burn clients,
requiring increased caloric and protein intake. Delayed wound healing may be an issue if proper
care is not given to the wound sites. Delirium can also occur in some clients.
Administering enteral feeding is a common intervention for burn clients due to their increased
caloric and protein needs. Providing high protein, high-calorie meals is important to promote -
CORRECT ANSWER -wound healing. Placing a nasogastric tube for feeding can be a
method to ensure the client receives adequate nutrition. Monitoring albumin and total protein
levels is vital to assess the client's nutritional status and fluid balance, ensuring proper healing
and minimizing complications.
A duodenal feeding tube (long-term nutritional support) is commonly used for clients with
extensive burns because it allows for - CORRECT ANSWER -continuous feeding,
reducing the risk of aspiration and ensuring adequate nutrient delivery, especially when the client
is unable to consume food orally.
NGT can be inserted for feeding or for relieving gastric distention, which occurs when the
stomach fills with air or fluids, which can be a sign that the NGT is not - CORRECT
ANSWER -effectively draining the stomach. This can increase the risk of complications
such as aspiration, nausea, and vomiting, especially in a burn client who is receiving massive
fluid resuscitation.
Questions and CORRECT Answers
Superficial burns- Minimal damage to the epidermis, - CORRECT ANSWER -Dry, no
blisters; pink or red; blanches easily, Hypersensitive. 3-7 days with no scarring
Superficial partial-thickness burns- Entire epidermis and minimal damage to the dermis, -
CORRECT ANSWER -Blisters that may be closed or open and weeping; pink or red; mild
edema; blanches easily, Hypersensitive. 7-14 days with no scarring
Deep partial-thickness burns- Entire epidermis and deeper layers of the dermis, - CORRECT
ANSWER -Blisters that may be closed or open; waxy appearance; cherry red, mottled, or
pale in the center; edema; sluggish or no blanching, Hypersensitive around the wound edges but
may be sensitive to pressure only in the center. Healing may take 3-6 weeks and may leave some
scarring, or the wound may have to be surgically excised and grafted.
Full-thickness burns - Destruction of entire epidermis and dermis; may involve subcutaneous fat,
muscle, and/or bone, - CORRECT ANSWER -Dry, leathery; pale, white, brown, tan,
black, charred; no blanching; may be contracted if muscle involvement, No pain in the center of
the wound but may be sensitive to pressure. Will not heal without surgical excision and grafting
Fluid and Electrolyte Changes in the Emergent Phase - CORRECT ANSWER -
Generalized dehydration, Reduction in blood volume, Decreased urinary output, Hyperkalemia,
Hyponatremia, Metabolic acidosis, Elevated hematocrit
Fluid shift or capillary leak syndrome is a continuous leak of plasma from the vascular space into
the interstitial space. This is - CORRECT ANSWER -third spacing. Because of third
spacing, Excess weight gain occurs in the first 12 hours after a burn and can continue for 24-36
hours.
In burn clients, especially those involved in explosions or fires, inhalation injuries are a
significant concern. The airway must be - CORRECT ANSWER -assessed first to ensure it
is patent, and high-flow oxygen is administered to increase oxygen saturation and prevent
hypoxia.
,Facial burns, hoarseness, and singed nasal hairs suggest inhalation injury, which can lead to -
CORRECT ANSWER -rapid airway swelling. Early intubation is critical before the airway
becomes obstructed. Pain control and fluid resuscitation are also important but are not the first
priority in this scenario.
a patient has sustained a full-thickness burn to the entire chest and partial thickness burn to the
entire right arm. What is the TBSA?- - CORRECT ANSWER -45% (The full thickness
burns on the chest and abdomen account for 36% of the TBSA, as each of these areas is assigned
18% (9% for the front of the chest and 9% for the front of the abdomen). The partial thickness
burns on the entire right arm account for 9% of the TBSA. By adding 36% for the chest and
abdomen with 9% for the right arm, the total TBSA burn estimate is 45%.)
A client that has full thickness burns of the entire chest, and partial thickness burns of the entire
right arm. According to the rule of 9s, the entire chest is worth 18% while the entire arm is worth
9%. Therefore, the total body surface area burned is - CORRECT ANSWER -27%.
calculate the TBSA of a person who has sustained full-thickness burns to the poster head and
poster left arm - CORRECT ANSWER -9%.
Priority nursing intervention for partial thickness and full thickness burns - CORRECT
ANSWER -initiate a large-bore IV and infusion of 0.9% sodium chloride or Lactated
Ringer's.
In burn clients, especially those with burns covering a significant percentage of total body
surface area, fluid loss is a major concern due to increased capillary permeability and subsequent
third spacing. Adequate urine output—typically at least 30 to 50 mL/hr—and stable blood
pressure are key indicators that - CORRECT ANSWER -perfusion and renal function are
being maintained. In contrast, low urine output, delayed capillary refill, tachycardia, or signs of
fluid overload such as crackles in the lungs suggest inadequate or excessive fluid resuscitation
and require immediate reassessment of the treatment plan.
In major burn injuries, especially with deep full thickness burns, there is a significant risk of
fluid shifts due to the loss of integrity in the skin, leading to fluid and electrolyte imbalances.
Fluid resuscitation is crucial in the first 24-48 hours to prevent - CORRECT ANSWER -
, hypovolemic shock, stabilize blood pressure, and support organ function. The large bore IV
ensures that fluids can be administered quickly and efficiently. While pain management,
diuretics, and monitoring of intake and output are important aspects of care, fluid resuscitation is
the highest priority in the immediate post-burn period to address the risk of shock and organ
failure.
During the Emergent phase patients may experience delirium and fluctuating attention and
awareness. Educating the family and involving them in the client's care can - CORRECT
ANSWER -provide comfort and reduce anxiety, which may help prevent or mitigate
delirium. Family support is a critical element in managing delirium, as it can decrease confusion
and provide reassurance.
During the intermediate phase of burn recovery, the nurse should focus on wound infection, as
the loss of skin's protective barrier increases the risk for - CORRECT ANSWER -bacterial
invasion. Nutritional deficiencies are a concern due to the hypermetabolic state of burn clients,
requiring increased caloric and protein intake. Delayed wound healing may be an issue if proper
care is not given to the wound sites. Delirium can also occur in some clients.
Administering enteral feeding is a common intervention for burn clients due to their increased
caloric and protein needs. Providing high protein, high-calorie meals is important to promote -
CORRECT ANSWER -wound healing. Placing a nasogastric tube for feeding can be a
method to ensure the client receives adequate nutrition. Monitoring albumin and total protein
levels is vital to assess the client's nutritional status and fluid balance, ensuring proper healing
and minimizing complications.
A duodenal feeding tube (long-term nutritional support) is commonly used for clients with
extensive burns because it allows for - CORRECT ANSWER -continuous feeding,
reducing the risk of aspiration and ensuring adequate nutrient delivery, especially when the client
is unable to consume food orally.
NGT can be inserted for feeding or for relieving gastric distention, which occurs when the
stomach fills with air or fluids, which can be a sign that the NGT is not - CORRECT
ANSWER -effectively draining the stomach. This can increase the risk of complications
such as aspiration, nausea, and vomiting, especially in a burn client who is receiving massive
fluid resuscitation.
