Download NU 272: Tissue Integrity Questions With Complete Solutions 2025 Graded A+ Pass. and more Exams Nursing in PDF only on Docsity!
NU 272: Tissue Integrity Questions With Complete Solutions
2025 Graded A+ Pass.
Following a serious thermal burn, which complication will the nurse take action to prevent first? Tissue hypoxia Infection Renal failure Hypovolemia - ANSWERS-Hypovolemia After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn. Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? Mechanical Surgical Natural Chemical - ANSWERS-Mechanical
Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue. During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? Removing eschar from the skin Applying continuous-compression wraps Wearing clothing to protect the burn from the sun Maintaining wound care irrigation - ANSWERS-Applying continuous-compression wraps Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring. When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypernatremia. Hypocalcemia. Hypoglycemia. - ANSWERS-Hyperkalemia. Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? 90 g/day 110 g/day 180 g/day 270 g/day - ANSWERS-180 g/day Recommendations from recent literature advocate protein requirements of 1.5 to 2 g/kg/day (Saffle, Graves, & Cochran, 2012).
Prevent negative nitrogen balance in order to maximize healing A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue. - ANSWERS-Epidermis and a portion of deeper dermis. A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn. A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? Hyperactive bowel sounds Decreased peristalsis Fecal occult blood Hematemesis - ANSWERS-Decreased peristalsis
A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume. You were thinking about PaO2 which should be 95-100 mm Hg A child tips a pot of boiling water onto his bare legs. The mother should: Avoid touching the burned skin and take the child to the nearest emergency department. Cover the child's legs with ice cubes secured with a towel. Immerse the child's legs in cool water. Liberally apply butter or shortening to the burned areas. - ANSWERS-Immerse the child's legs in cool water. The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Gastric ulcers Hyperthyroidism
Cardiac arrest - ANSWERS-Gastric ulcers The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest. Which of the following is true regarding a split-thickness skin graft? Split thickness grafts are less successful than other types of grafts. Their cosmetic appearance are more desirable. Hair is able to grow back from their surface. The epidermis and a thin layer of dermis are harvested from the client's skin. - ANSWERS-The epidermis and a thin layer of dermis are harvested from the client's skin. In a split-thickness skin graft, the epidermis and a thin layer of the dermis are harvested from the client's skin. Their cosmetic appearance is less desirable. Hair does not grow back from their surface. Split thickness grafts are more successful that other types of grafts. The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? an alginate dressing transparent film
angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? Size Depth Tunneling Direction - ANSWERS-Depth When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection. The nurse caring for a postoperative client documents that the surgical incision is healing by: Primary intention Secondary intention Tertiary intention Systemic intention - ANSWERS-Primary intention Explanation:
The nurse would document the surgical wound as healing by primary intention as there is no tissue loss. Wounds healing from secondary intention are larger and have a greater loss of tissue and contamination. Wounds do not heal by tertiary intention or systemic intention. The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include? Apply a hydrocolloidal dressing. Place the extremity in a dependent position. Cleanse the area with hydrogen peroxide, and wrap with clean gauze. Restrict protein intake, and encourage fluids. - ANSWERS-Apply a hydrocolloidal dressing. Full-thickness skin loss occurs in a stage 3 pressure injury. WIth this type of injury, subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Treatment of this type of injury includes the use of a hydrocolloidal dressing because it forms an occlusive barrier over the area while maintaining a moist environment; this prevents infection, friction, and shear. The extremity should be elevated to reduce pain and improve blood flow. The area should not be cleansed with hydrogen peroxide as this will harm granulation tissue and prevent healing. The injury should be wrapped with sterile gauze to prevent infection. Protein intake should be encouraged to promote wound healing. Fluids should be encouraged to maintain adequate hydration for skin integrity. The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:
When documenting an acute open wound, the nurse should consider the wound's size, the condition of the periwound skin (skin surrounding the wound), a description of the wound bed, and the wound edges and margins. The pattern of eruption relates to the patterns of lesions on a client's skin and does not apply to an acute open wound. The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess? Pallor Edema Hypothermia Tissue necrosis - ANSWERS-Edema Cardinal signs of inflammation include rubor (redness), tumor (swelling or edema), calor (heat), dolor (pain) and functio laesa (loss of function). Tissue necrosis occurs with chronic inflammation. While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? Dry sterile dressing Sterile petroleum gauze Moist sterile saline gauze Povidone-iodine-soaked gauze - ANSWERS-Moist sterile saline gauze
Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound. A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? stage I stage II stage III stage IV - ANSWERS-stage III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle. On postoperative day 2, a client requires care for a surgical wound using second- intention healing. What type of dressing change should the nurse anticipate doing? Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Covering the well-approximated wound edges with a dry dressing
