NURS 272 Exam 4 Study Questions and
Answers 2024
Which clinical manifestations would the nurse anticipate while caring for a patient with
third-degree burns? Select all that apply.
1 Erythema
2 Fluid-filled vesicles
3 Hard, leathery skin
4 Insensitivity to pain
5 Mild to moderate edema - Correct Ans-3 Hard, leathery skin
4 Insensitivity to pain
Third-degree burns cause full-thickness skin destruction. Clinical manifestations include
hard, leathery skin and insensitivity to pain due to nerve destruction. Erythema is
observed in first-degree burns. Second-degree burns are characterized by fluid-filled
vesicles and mild to moderate edema.
According to the Rule of Nines for calculating the percentage of burns, the nurse would
assign which percentage to a burn in the genitalia?
1 1%
2 4.5%
3 9%
4 18% - Correct Ans-1 1%
The Rule of Nines is a formula used for calculating the percentage of burns during initial
assessment of a burn patient. The genitals are assigned 1%. Burns in the head and
arms are assigned 9% each. Burns on the lower extremities are assigned 18% each.
Burns in the chest and back are assigned 18% for each side
A patient has sustained burns on the face, neck, and chest. Which additional
assessment findings would alert the nurse to an upper airway injury? Select all that
apply.
1 Dyspnea
2 Wheezing
3 Hoarseness
4 Singed nasal hair
5 Difficulty in swallowing - Correct Ans-3 Hoarseness
5 Difficulty in swallowing
Upper airway injury may be caused by thermal burns or the inhalation of hot air, steam,
or smoke. Hoarseness occurs due to laryngeal edema in the upper airway. Difficulty in
swallowing is present due to edema and blistering of the oropharynx in the upper
,airway. Dyspnea can be observed where there has been an inhalation injury to the
lower airway that is caused by breathing toxic chemicals or smoke that affects the
trachea, bronchioles, and alveoli. Wheezing is a symptom found in an inhalation injury
affecting the lower airway. Singed nasal hair (along with burned facial hair) is an
indicator of inhaled burn particles or smoke and is an indicator of lower airway injury.
Which factors lead the nurse to believe that a patient with severe burns on the legs and
feet may have full-thickness burns? Select all that apply.
1 Touch sensation is impaired.
2 Blanching with pressure is observed.
3 Lack of blanching with pressure is observed.
4 Wounds appear mottled white, pink to cherry red.
5 Wounds appear waxy white, dark brown, or charred. - Correct Ans-1 Touch sensation
is impaired.
3 Lack of blanching with pressure is observed.
5 Wounds appear waxy white, dark brown, or charred.
Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack
of blanching with pressure is observed because all skin elements are destroyed.
Wounds appear waxy white, dark brown, or charred in full-thickness burns because all
skin elements and local nerve endings are destroyed, and coagulation necrosis is
present. Blanching with pressure is observed in partial-thickness burns because varying
degrees of both the epidermis and dermis are involved, and skin elements of
regeneration are viable. Wounds appear mottled white, pink to cherry red in a partial-
thickness 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 requirements."
4 "A hypermetabolic state results in poor healing and increased protein and lipid needs."
- Correct Ans-4 "A hypermetabolic state results in poor healing and increased protein
and lipid needs."
A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism
that can inhibit wound healing. Therefore, the patient with a burn injury requires
increased calories and protein to enable the healing process. Protein intake in the burn
patient should be increased to promote 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 desired and is a complication of a burn injury. Controlling the
temperature of the environment has no effect on caloric requirements.
, A burn patient with moist, red, shiny vesicles and blister formation reports severe pain
when the site is exposed to air. Which type of burn would the nurse document in the
patient's medical record?
1 First-degree burn
2 Third-degree burn
3 Fourth-degree burn
4 Second-degree burn - Correct Ans-4 Second-degree burn
A second-degree burn manifests as a bright-red burned area with moist, red, shiny
vesicles and blister formation. There is also severe pain upon exposure to air. In first-
degree burns, there is erythema, blanching on application of pressure, and no vesicles
or blisters. Third- and fourth-degree burns are characterized by dry, waxy, leathery skin
that is insensitive to pain.
Which manifestations would the nurse expect when admitting a patient with a full
thickness thermal burn?
1 Severe pain, blisters, and blanching with pressure
2 Pain, minimal edema, and blanching with pressure
3 Redness, evidence of inhalation injury, and charred skin
4 No pain, waxy white skin, and no blanching with pressure - Correct Ans-4 No pain,
waxy white skin, and no blanching with pressure
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so
there is no pain; the tissue is dry and waxy looking or may be charred, and there is no
blanching with pressure. Severe pain, blisters, and blanching occur with partial-
thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness
occur with partial-thickness (superficial, first-degree) burns
When assessing a patient with a second-degree burn, which clinical manifestations
would the nurse anticipate? Select all that apply.
1 Blanching
2 Severe pain
3 White, waxy skin
4 Red, shiny vesicles
5 Mild to moderate edema - Correct Ans-2 Severe pain
4 Red, shiny vesicles
5 Mild to moderate edema
Clinical manifestations of second-degree burns include severe pain, the appearance of
fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema.
Blanching is observed in first-degree burns, and white, waxy skin is seen in third- and
fourth-degree burns.
