NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
Which prevention strategy would the nurse include when teaching about home fire safety?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended. - ANSWER C. Encourage regular home fire exit drills
The injury that is least likely to result in a full-thickness burn is
a. sunburn.
b. scald injury.
c. chemical burn.
d. electrical injury. - ANSWER A. Sunburn
When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that
apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance. - ANSWER a. blisters.
,NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
d. intact nerve endings.
e. red, shiny, wet appearance.
A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest
after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung
fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Which
action is the most appropriate for the nurse to take next?
a. Encourage the patient to cough and auscultate the lungs again.
b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.
c. Document the findings and continue to monitor the patient's breathing.
d. Anticipate the need for endotracheal intubation and notify the provider. - ANSWER d. Anticipate the
need for endotracheal intubation and notify the provider.
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. movement of sodium and water into the interstitial space.
d. hemolysis of red blood cells from large volumes of rapidly administered fluid. - ANSWER c. movement
of sodium and water into the interstitial space.
To maintain a positive nitrogen balance in a major burn, the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about four times.
c. eat at least 1500 calories/day in small, frequent meals.
,NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
d. eat a gluten-free diet for the chemical effect on nitrogen balance. - ANSWER a. eat a high-protein,
high-carbohydrate diet.
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-
impregnated dressing. The nurse's priority intervention for wound care would be to
a. reapply a new dressing without disturbing the wound bed.
b. observe the wound for signs of infection during dressing changes.
c. apply cool compresses for pain relief in between dressing changes.
d. wash the wound aggressively with soap and water three times a day. - ANSWER b. observe the wound
for signs of infection during dressing changes.
Pain management for the burn patient is most effective when (select all that apply)
a. a pain rating tool is used to monitor the patient's level of pain.
b. painful dressing changes are delayed until the patient's pain is completely relieved.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant
analgesics).
e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation
phase of a burn injury. - ANSWER a. a pain rating tool is used to monitor the patient's level of pain.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant
analgesics).
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn
recovery is
a. applying pressure garments.
, NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
b. repositioning the patient every 2 hours.
c. performing active ROM at least every 4 hours.
d. massaging the new tissue with water-based moisturizers. - ANSWER a. applying pressure garments.
A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care
team is planning for discharge. The first action the nurse should take when meeting with the patient
would be to
a. arrange a return-to-clinic appointment and prescription for pain medications.
b. teach the patient and the caregiver proper wound care to be performed at home.
c. review the patient's current health care status and readiness for discharge to home.
d. give the patient written information and websites for information for burn survivors. - ANSWER c.
review the patient's current health care status and readiness for discharge to home.
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which
level of injury does the nurse associate with this degree of recovery?
a. L1-2
b. T6-7
c. T1-2
d. C7-8 - ANSWER a. L1-2
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system
dysfunction. What would the nurse recognize as characteristic of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
Mobility 209 questions and solutions
100% correct.
NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
Which prevention strategy would the nurse include when teaching about home fire safety?
a. Set hot water temperature at 140°F.
b. Use only hardwired smoke detectors.
c. Encourage regular home fire exit drills.
d. Do not allow older adults to cook unattended. - ANSWER C. Encourage regular home fire exit drills
The injury that is least likely to result in a full-thickness burn is
a. sunburn.
b. scald injury.
c. chemical burn.
d. electrical injury. - ANSWER A. Sunburn
When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that
apply)
a. blisters.
b. exposed fascia.
c. exposed muscles.
d. intact nerve endings.
e. red, shiny, wet appearance. - ANSWER a. blisters.
,NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
d. intact nerve endings.
e. red, shiny, wet appearance.
A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest
after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung
fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Which
action is the most appropriate for the nurse to take next?
a. Encourage the patient to cough and auscultate the lungs again.
b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas.
c. Document the findings and continue to monitor the patient's breathing.
d. Anticipate the need for endotracheal intubation and notify the provider. - ANSWER d. Anticipate the
need for endotracheal intubation and notify the provider.
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include
a. adherence of albumin to vascular walls.
b. movement of potassium into the vascular space.
c. movement of sodium and water into the interstitial space.
d. hemolysis of red blood cells from large volumes of rapidly administered fluid. - ANSWER c. movement
of sodium and water into the interstitial space.
To maintain a positive nitrogen balance in a major burn, the patient must
a. eat a high-protein, high-carbohydrate diet.
b. increase normal caloric intake by about four times.
c. eat at least 1500 calories/day in small, frequent meals.
,NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
d. eat a gluten-free diet for the chemical effect on nitrogen balance. - ANSWER a. eat a high-protein,
high-carbohydrate diet.
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-
impregnated dressing. The nurse's priority intervention for wound care would be to
a. reapply a new dressing without disturbing the wound bed.
b. observe the wound for signs of infection during dressing changes.
c. apply cool compresses for pain relief in between dressing changes.
d. wash the wound aggressively with soap and water three times a day. - ANSWER b. observe the wound
for signs of infection during dressing changes.
Pain management for the burn patient is most effective when (select all that apply)
a. a pain rating tool is used to monitor the patient's level of pain.
b. painful dressing changes are delayed until the patient's pain is completely relieved.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant
analgesics).
e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation
phase of a burn injury. - ANSWER a. a pain rating tool is used to monitor the patient's level of pain.
c. the patient is informed about and has some control over the management of the pain.
d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant
analgesics).
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn
recovery is
a. applying pressure garments.
, NURS 272 Exam 4: Tissue Integrity and
Mobility 209 questions and solutions
100% correct.
b. repositioning the patient every 2 hours.
c. performing active ROM at least every 4 hours.
d. massaging the new tissue with water-based moisturizers. - ANSWER a. applying pressure garments.
A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care
team is planning for discharge. The first action the nurse should take when meeting with the patient
would be to
a. arrange a return-to-clinic appointment and prescription for pain medications.
b. teach the patient and the caregiver proper wound care to be performed at home.
c. review the patient's current health care status and readiness for discharge to home.
d. give the patient written information and websites for information for burn survivors. - ANSWER c.
review the patient's current health care status and readiness for discharge to home.
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which
level of injury does the nurse associate with this degree of recovery?
a. L1-2
b. T6-7
c. T1-2
d. C7-8 - ANSWER a. L1-2
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system
dysfunction. What would the nurse recognize as characteristic of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
