NURS 272 Exam 4 Questions And Correct Answers
What clinical manifestations does the nurse expect to observe when providing care for a
client with third-degree burns?
1 Redness
2 Fluid-filled blisters
3 Tough, leather-like skin
4 Absence of pain
5 Mild to moderate edema ANS 3 Tough, leather-like skin
4 Absence of pain
Full-thickness destruction of skin characterizes third-degree burns. Clinical
manifestations include hard, leathery skin and insensitivity to pain due to the
destruction of nerves. First-degree burns present with erythema. Second-degree burns
present with fluid-filled vesicles and mild to moderate edema.
Rule of Nines for calculating the percentage of burns, what percentage would the nurse
assign to a burn in the genitalia?
1 1%
2 4.5%
3 9%
4 18% - ANSWER 1 1%
The Rule of Nines is a formula used in initial assessment to find the percentage of a
patient's burns. The genital is assigned 1%. Burns in the head and arms are assigned 9%
each. Burns on the lower extremities are assigned 18% each. Burns in chest and back
are assigned 18% each side.
Burns of the face, neck, and anterior chest have been sustained by a patient. Which of
,the following additional assessment findings would lead the nurse to suspect an injury to
the upper airway?
1 Dyspnea
2 Wheezing
3 Hoarseness
4 Singed nasal hair
5 Difficulty in swallowing - ANSWER 3 Hoarseness
5 Difficulty in swallowing
The upper airway can be injured from a thermal burn or from the inhalation of hot air,
steam, or smoke. The hoarseness arises because of the laryngeal edema that occurs in
the upper airway. Difficulty in swallowing due to edema and blistering is present in the
oropharynx of the upper airway. Dyspnea can be observed where there has been an
inhalation injury to the lower airway that arises due to inhalation of toxic chemicals or
smoke that affects the trachea, bronchioles, and alveoli. Wheezing is a symptom related
to an inhalation injury involving the lower airway. Singed nasal hair (and burned facial
hair) indicates that burn particles or smoke have been inhaled and suggests lower
airway injury.
Which of the following factors influence the nurse to suspect that a client who has
sustained serious burns of the legs and feet may have full-thickness burns? Select those
that apply.
1 Loss of sensation to touch.
2 Blanching with pressure is noted.
3 There is no blanching with pressure.
4 Wounds are mottled white, pink to cherry red.
5 Wounds are waxy white, dark brown or charred. - ANSWER 1 Touch sensation is
absent.
3 There is no blanching with pressure.
5 Wounds are waxy white, dark brown or charred.
, Touch sensation is absent due to destroyed nerve endings in full-thickness burns. Lack
of blanching with pressure is noted because all skin elements are destroyed.
Full-thickness burns will present a waxy white, dark brown, or charred wound because
all skin elements are destroyed, including local nerve endings, and there is coagulation
necrosis present. Blanching to pressure is present in partial-thickness burns because
either partial or a portion of both the epidermis and dermis is affected, and the skin
elements of regeneration remain viable. Wounds appear mottled white, pink to cherry
red in a partialthickness burn.
A nurse is planning care for a patient with a 30% body surface area burn injury. Which
statement by the nurse regarding the nutritional status of this patient is true?
1 "Maintaining a hypermetabolic state reduces the patient's risk for infection."
2 "Decreased protein intake will decrease the chance of renal complications."
3 "Controlling the temperature of the environment reduces caloric needs".
4 "A hypermetabolic state leads to poor healing with an increased need for protein and
lipids." - 4 "A hypermetabolic state leads to poor healing with an increased need for
protein and lipids."
A burn injury creates a hypermetabolic state and protein and lipid catabolism that may
impede the wound-healing process. Thus, the burned patient requires more calories
and protein to allow healing to take place. Protein in the burn patient should be
increased to aid in wound healing. Renal function is monitored for complications, which
is low risk with burns because the need for protein is increased. A hypermetabolic state
is not desirable and a complication of the burn injury. This does not change the patient's
caloric requirement.
A patient with a burn injury presents with moist, red, shiny vesicles and the formation of
blisters with severe pain when the site is exposed to the air. The nurse would record
what stage of burn in the patient's chart?
1 First-degree burn
2 Third-degree burn
What clinical manifestations does the nurse expect to observe when providing care for a
client with third-degree burns?
1 Redness
2 Fluid-filled blisters
3 Tough, leather-like skin
4 Absence of pain
5 Mild to moderate edema ANS 3 Tough, leather-like skin
4 Absence of pain
Full-thickness destruction of skin characterizes third-degree burns. Clinical
manifestations include hard, leathery skin and insensitivity to pain due to the
destruction of nerves. First-degree burns present with erythema. Second-degree burns
present with fluid-filled vesicles and mild to moderate edema.
Rule of Nines for calculating the percentage of burns, what percentage would the nurse
assign to a burn in the genitalia?
1 1%
2 4.5%
3 9%
4 18% - ANSWER 1 1%
The Rule of Nines is a formula used in initial assessment to find the percentage of a
patient's burns. The genital is assigned 1%. Burns in the head and arms are assigned 9%
each. Burns on the lower extremities are assigned 18% each. Burns in chest and back
are assigned 18% each side.
Burns of the face, neck, and anterior chest have been sustained by a patient. Which of
,the following additional assessment findings would lead the nurse to suspect an injury to
the upper airway?
1 Dyspnea
2 Wheezing
3 Hoarseness
4 Singed nasal hair
5 Difficulty in swallowing - ANSWER 3 Hoarseness
5 Difficulty in swallowing
The upper airway can be injured from a thermal burn or from the inhalation of hot air,
steam, or smoke. The hoarseness arises because of the laryngeal edema that occurs in
the upper airway. Difficulty in swallowing due to edema and blistering is present in the
oropharynx of the upper airway. Dyspnea can be observed where there has been an
inhalation injury to the lower airway that arises due to inhalation of toxic chemicals or
smoke that affects the trachea, bronchioles, and alveoli. Wheezing is a symptom related
to an inhalation injury involving the lower airway. Singed nasal hair (and burned facial
hair) indicates that burn particles or smoke have been inhaled and suggests lower
airway injury.
Which of the following factors influence the nurse to suspect that a client who has
sustained serious burns of the legs and feet may have full-thickness burns? Select those
that apply.
1 Loss of sensation to touch.
2 Blanching with pressure is noted.
3 There is no blanching with pressure.
4 Wounds are mottled white, pink to cherry red.
5 Wounds are waxy white, dark brown or charred. - ANSWER 1 Touch sensation is
absent.
3 There is no blanching with pressure.
5 Wounds are waxy white, dark brown or charred.
, Touch sensation is absent due to destroyed nerve endings in full-thickness burns. Lack
of blanching with pressure is noted because all skin elements are destroyed.
Full-thickness burns will present a waxy white, dark brown, or charred wound because
all skin elements are destroyed, including local nerve endings, and there is coagulation
necrosis present. Blanching to pressure is present in partial-thickness burns because
either partial or a portion of both the epidermis and dermis is affected, and the skin
elements of regeneration remain viable. Wounds appear mottled white, pink to cherry
red in a partialthickness burn.
A nurse is planning care for a patient with a 30% body surface area burn injury. Which
statement by the nurse regarding the nutritional status of this patient is true?
1 "Maintaining a hypermetabolic state reduces the patient's risk for infection."
2 "Decreased protein intake will decrease the chance of renal complications."
3 "Controlling the temperature of the environment reduces caloric needs".
4 "A hypermetabolic state leads to poor healing with an increased need for protein and
lipids." - 4 "A hypermetabolic state leads to poor healing with an increased need for
protein and lipids."
A burn injury creates a hypermetabolic state and protein and lipid catabolism that may
impede the wound-healing process. Thus, the burned patient requires more calories
and protein to allow healing to take place. Protein in the burn patient should be
increased to aid in wound healing. Renal function is monitored for complications, which
is low risk with burns because the need for protein is increased. A hypermetabolic state
is not desirable and a complication of the burn injury. This does not change the patient's
caloric requirement.
A patient with a burn injury presents with moist, red, shiny vesicles and the formation of
blisters with severe pain when the site is exposed to the air. The nurse would record
what stage of burn in the patient's chart?
1 First-degree burn
2 Third-degree burn
