NUR 220 | NUR 220 Medical Surgical Nursing Exam
4 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient arrives in the emergency department with a deep partial-thickness burn
to the chest and abdomen. Which clinical finding should the nurse expect to observe
during the assessment of this type of burn?
A. A pink to red appearance with large, fluid-filled blisters.
B. A dry, waxy white appearance with no blanching.
C. A painless area that is charred and leathery.
D. Mild erythema with no blister formation.
Correct Answer: A
Expert Explanation: Deep partial-thickness burns involve the epidermis and much
of the dermis, typically presenting with blisters and significant pain. The wound bed
is usually red to pale in color and very moist due to plasma leakage. In contrast, full-
thickness burns are painless because the nerve endings are destroyed. Superficial
burns only involve the epidermis and lack blisters. Proper assessment is vital to
determine the correct fluid resuscitation requirements for the patient.
,2. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) for an adult
patient with burns to the entire left arm and the entire anterior trunk.
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Expert Explanation: According to the Rule of Nines, the entire left arm accounts for
9% of the TBSA. The anterior trunk (chest and abdomen) accounts for 18% of the
TBSA. Adding these two percentages together results in a total of 27%. Accurate
TBSA calculation is necessary to implement the Parkland formula for fluid
resuscitation. Miscalculating these values can lead to dangerous under-resuscitation
or over-resuscitation in burn patients.
3. A patient with a Stage 4 pressure injury on the sacrum is scheduled for
debridement. The nurse identifies which characteristic as being consistent with a
Stage 4 injury?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer.
B. Full-thickness skin loss where subcutaneous fat is visible but not bone.
,C. Intact skin with non-blanchable redness of a localized area.
D. Full-thickness tissue loss with visible bone, tendon, or muscle.
Correct Answer: D
Expert Explanation: A Stage 4 pressure injury is characterized by full-thickness
tissue loss with exposed bone, tendon, or muscle. Often, slough or eschar may be
present on some parts of the wound bed. This stage poses a high risk for
osteomyelitis due to the deep tissue involvement. Stage 3 involves subcutaneous fat
but does not reach the muscle or bone level. Frequent assessment and specialized
support surfaces are required to prevent further deterioration of such deep wounds.
4. A nurse is providing teaching to a patient receiving external beam radiation therapy
for lung cancer. Which instruction should be included regarding skin care in the
treatment field?
A. Apply a heating pad to the area to increase circulation.
B. Vigorously scrub the treatment area to remove dead skin cells.
C. Apply over-the-counter medicated lotions to the area twice daily.
D. Wash the area gently with lukewarm water and a mild, fragrance-free soap.
Correct Answer: D
, Expert Explanation: Radiation therapy can cause skin sensitivity, dryness, and
breakdown in the targeted treatment area. Patients should use only lukewarm
water and mild soaps to prevent further irritation. It is essential to avoid scrubbing
the skin or applying extreme temperatures like heating pads. Patting the skin dry
rather than rubbing it helps maintain the integrity of the weakened skin. Nurses
must emphasize protecting the area from direct sunlight and avoiding non-
prescribed ointments.
5. During the emergent phase of burn management, which laboratory result would the
nurse most likely expect to see?
A. Hypernatremia and hypokalemia.
B. Low hemoglobin and low hematocrit.
C. Hyponatremia and hyperkalemia.
D. Metabolic alkalosis.
Correct Answer: C
Expert Explanation: In the emergent phase of a burn, massive fluid shifts cause
sodium to move into the interstitial space, resulting in hyponatremia. Potassium is
released from damaged cells into the bloodstream, leading to hyperkalemia.
Hematocrit levels typically rise because of hemoconcentration due to fluid loss.
Metabolic acidosis is also common as a result of poor tissue perfusion and lactic acid
4 Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient arrives in the emergency department with a deep partial-thickness burn
to the chest and abdomen. Which clinical finding should the nurse expect to observe
during the assessment of this type of burn?
A. A pink to red appearance with large, fluid-filled blisters.
B. A dry, waxy white appearance with no blanching.
C. A painless area that is charred and leathery.
D. Mild erythema with no blister formation.
Correct Answer: A
Expert Explanation: Deep partial-thickness burns involve the epidermis and much
of the dermis, typically presenting with blisters and significant pain. The wound bed
is usually red to pale in color and very moist due to plasma leakage. In contrast, full-
thickness burns are painless because the nerve endings are destroyed. Superficial
burns only involve the epidermis and lack blisters. Proper assessment is vital to
determine the correct fluid resuscitation requirements for the patient.
,2. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) for an adult
patient with burns to the entire left arm and the entire anterior trunk.
A. 18%
B. 45%
C. 36%
D. 27%
Correct Answer: D
Expert Explanation: According to the Rule of Nines, the entire left arm accounts for
9% of the TBSA. The anterior trunk (chest and abdomen) accounts for 18% of the
TBSA. Adding these two percentages together results in a total of 27%. Accurate
TBSA calculation is necessary to implement the Parkland formula for fluid
resuscitation. Miscalculating these values can lead to dangerous under-resuscitation
or over-resuscitation in burn patients.
3. A patient with a Stage 4 pressure injury on the sacrum is scheduled for
debridement. The nurse identifies which characteristic as being consistent with a
Stage 4 injury?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer.
B. Full-thickness skin loss where subcutaneous fat is visible but not bone.
,C. Intact skin with non-blanchable redness of a localized area.
D. Full-thickness tissue loss with visible bone, tendon, or muscle.
Correct Answer: D
Expert Explanation: A Stage 4 pressure injury is characterized by full-thickness
tissue loss with exposed bone, tendon, or muscle. Often, slough or eschar may be
present on some parts of the wound bed. This stage poses a high risk for
osteomyelitis due to the deep tissue involvement. Stage 3 involves subcutaneous fat
but does not reach the muscle or bone level. Frequent assessment and specialized
support surfaces are required to prevent further deterioration of such deep wounds.
4. A nurse is providing teaching to a patient receiving external beam radiation therapy
for lung cancer. Which instruction should be included regarding skin care in the
treatment field?
A. Apply a heating pad to the area to increase circulation.
B. Vigorously scrub the treatment area to remove dead skin cells.
C. Apply over-the-counter medicated lotions to the area twice daily.
D. Wash the area gently with lukewarm water and a mild, fragrance-free soap.
Correct Answer: D
, Expert Explanation: Radiation therapy can cause skin sensitivity, dryness, and
breakdown in the targeted treatment area. Patients should use only lukewarm
water and mild soaps to prevent further irritation. It is essential to avoid scrubbing
the skin or applying extreme temperatures like heating pads. Patting the skin dry
rather than rubbing it helps maintain the integrity of the weakened skin. Nurses
must emphasize protecting the area from direct sunlight and avoiding non-
prescribed ointments.
5. During the emergent phase of burn management, which laboratory result would the
nurse most likely expect to see?
A. Hypernatremia and hypokalemia.
B. Low hemoglobin and low hematocrit.
C. Hyponatremia and hyperkalemia.
D. Metabolic alkalosis.
Correct Answer: C
Expert Explanation: In the emergent phase of a burn, massive fluid shifts cause
sodium to move into the interstitial space, resulting in hyponatremia. Potassium is
released from damaged cells into the bloodstream, leading to hyperkalemia.
Hematocrit levels typically rise because of hemoconcentration due to fluid loss.
Metabolic acidosis is also common as a result of poor tissue perfusion and lactic acid
