NURS 272 Exam 4- Tissue Integrity and
Mobility Questions With Correct Answers
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. |- |CORRECT |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. |- |CORRECT |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. |- |CORRECT |ANSWER✔✔-a. |blisters.
,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. |- |CORRECT |
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. |- |CORRECT |
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.
d. |eat |a |gluten-free |diet |for |the |chemical |effect |on |nitrogen |balance. |- |CORRECT |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. |- |CORRECT |
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. |- |CORRECT |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.
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. |- |CORRECT |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. |- |
CORRECT |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 |- |CORRECT |ANSWER✔✔-a. |L1-2
Mobility Questions With Correct Answers
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. |- |CORRECT |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. |- |CORRECT |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. |- |CORRECT |ANSWER✔✔-a. |blisters.
,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. |- |CORRECT |
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. |- |CORRECT |
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.
d. |eat |a |gluten-free |diet |for |the |chemical |effect |on |nitrogen |balance. |- |CORRECT |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. |- |CORRECT |
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. |- |CORRECT |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.
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. |- |CORRECT |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. |- |
CORRECT |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 |- |CORRECT |ANSWER✔✔-a. |L1-2
