NURS 272 Exam 4.pdf

NURS 272 Exam 4: Tissue Integrity
and Mobility with correct answers
2025



Which prevention strategy would the nurse include when teaching about home fire safety?
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a. Set hot water temperature at 140°F.
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b. Use only hardwired smoke detectors.
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c. Encourage regular home fire exit drills.
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d. Do not allow older adults to cook unattended. - correct-answers-
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C. Encourage regular home fire exit drills
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The injury that is least likely to result in a full-thickness burn is
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a. sunburn.
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b. scald injury.
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c. chemical burn.
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,d. electrical injury. - correct-answers-A. Sunburn
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When assessing a patient with a partial-
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thickness burn, the nurse would expect to find (select all that apply)
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a. blisters.
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b. exposed fascia.
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c. exposed muscles.
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d. intact nerve endings.
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e. red, shiny, wet appearance. - correct-answers-a. blisters.
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d. intact nerve endings.
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e. red, shiny, wet appearance.
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A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior ches
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t after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lun
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g fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Whi
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ch action is the most appropriate for the nurse to take next?
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a. Encourage the patient to cough and auscultate the lungs again.
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b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.
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c. Document the findings and continue to monitor the patient's breathing.
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d. Anticipate the need for endotracheal intubation and notify the provider. - correct-answers-
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d. Anticipate the need for endotracheal intubation and notify the provider.
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Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include
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a. adherence of albumin to vascular walls.
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,b. movement of potassium into the vascular space.
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c. movement of sodium and water into the interstitial space.
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d. hemolysis of red blood cells from large volumes of rapidly administered fluid. - correct-answers-
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c. movement of sodium and water into the interstitial space.
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To maintain a positive nitrogen balance in a major burn, the patient must
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a. eat a high-protein, high-carbohydrate diet.
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b. increase normal caloric intake by about four times.
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c. eat at least 1500 calories/day in small, frequent meals.
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d. eat a gluten-free diet for the chemical effect on nitrogen balance. - correct-answers-a. eat a high-
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protein, high-carbohydrate diet. v v




A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silve
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r-impregnated dressing. The nurse's priority intervention for wound care would be to
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a. reapply a new dressing without disturbing the wound bed.
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b. observe the wound for signs of infection during dressing changes.
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c. apply cool compresses for pain relief in between dressing changes.
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d. wash the wound aggressively with soap and water three times a day. - correct-answers-
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b. observe the wound for signs of infection during dressing changes.
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Pain management for the burn patient is most effective when (select all that apply)
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a. a pain rating tool is used to monitor the patient's level of pain.
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b. painful dressing changes are delayed until the patient's pain is completely relieved.
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c. the patient is informed about and has some control over the management of the pain.
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, d. a multimodal approach is used (e.g., sustained-release and short-
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acting opioids, NSAIDs, adjuvant analgesics).
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e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitatio
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n phase of a burn injury. - correct-answers-
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a. a pain rating tool is used to monitor the patient's level of pain.
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c. the patient is informed about and has some control over the management of the pain.
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d. a multimodal approach is used (e.g., sustained-release and short-
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acting opioids, NSAIDs, adjuvant analgesics).
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A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of bur
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n recovery is
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a. applying pressure garments.
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b. repositioning the patient every 2 hours.
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c. performing active ROM at least every 4 hours.
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d. massaging the new tissue with water-based moisturizers. - correct-answers-
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a. applying pressure garments.
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A patient is recovering from second- and third-
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degree burns over 30% of his body, and the burn care team is planning for discharge. The first action t
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he nurse should take when meeting with the patient would be to
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a. arrange a return-to-clinic appointment and prescription for pain medications.
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b. teach the patient and the caregiver proper wound care to be performed at home.
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c. review the patient's current health care status and readiness for discharge to home.
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d. give the patient written information and websites for information for burn survivors. - correct-
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answers-c. review the patient's current health care status and readiness for discharge to home.
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