NURS117 INTEGUMENTARY EXAM QUESTIONS
WITH ANSWERS GRADED A+
1. A nurse is caring for a burn client who has sustained thoracic burns
and smoke inhalation and is risk for impaired gas exchange. The nurse
avoids which action in caring for this client?
a. repositioning the client from side to side every 2 hours
b. maintaining the client in a supine position with the head of
the bed elevated
c. suctioning the airway as needed
d. providing humidified oxygen as prescribed
Aggressive pulmonary measures are used to prevent respiratory
complications in the client who has impaired gas exchange as a result of a
burn injury. These include turning and repositioning, positioning for comfort,
using humidified oxygen, providing incentive spirometry, and suctioning the
client on an as needed basis. The nurse would avoid maintaining the client in
one position. This will ultimately lead to atelectasis and possible pneumonia.
2. A client sustains a burn injury to the entire right arm, entire right leg,
and anterior thorax. According to the rule of nine’s the nurse
determines that what body percent was injured?
Answer: 45%
According to the Rule of Nine’s, the right arm is equal to 9% and the left arm
is equal to 9%. The right leg is equal to 18% and the left leg is equal to
18%. The anterior thorax is equal to 18% and the posterior thorax is equal
to 18%. The head is equal to 9% and the perineum is 1%. If the anterior
thorax (18%), entire right leg (18%), and entire right arm (9%) were
burned, according to the Rule of Nine’s, this would equal 45%.
3. A nurse assesses a burn injury and determines that the client
sustained a full-thickness fourth-degree burn if which of the following
is noted at the site of injury?
a. a wet shiny weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. blisters
In a full-thickness fourth-degree burn injury, charring is visible. Extremity
movement is limited and wound sensation is absent. Blisters and a wet shiny
,NURS117 INTEGUMENTARY EXAM QUESTIONS
WITH ANSWERS GRADED A+
weeping surface would be noted in a partial-thickness second-degree burn
injury. A dry wound surface would be noted in a full-thickness third-degree
burn injury.
4. A client is brought to the emergency room following a burn injury. In
assessment the nurse notes that the client’s eyebrow and nasal hairs
are singed. The nurse would identify this type of burn as:
a. thermal
b. electrical
c. radiation
d. chemical
Exposure to or contact with flames, hot liquids, or hot objects causes thermal
burns. Thermal burns are those sustained in residential fires, explosive
accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes
facial burns or singed eyebrow or nasal hairs, the victim likely experienced
the burn in an enclosed smoke filled space such as in a residential fire.
Electrical burns are caused by heat that is generated by the electrical energy
as it passes through the body. Radiation burns are caused by exposure to a
radioactive source. Chemical burns are caused by tissue contact with strong
acids, alkalis, or organic compounds.
5. A nurse assesses the carbon monoxide level of a client following a
burn injury and notes that the level is 8%. Based on this level, which
finding would the nurse expect to note during the assessment of the
client?
a. tachycardia
b. tachypnea
c. coma
d. impaired visual acuity
Clinical manifestations of carbon monoxide poisoning are related to the levels
of carbon monoxide saturation. A level between 5 to 10% would cause
impaired visual acuity; 11 to 20% flushing and headache; 21 to 30% nausea
and impaired dexterity; 31 to 40% vomiting, dizziness, and syncope; 41 to
50% tachypnea and tachycardia; and greater than 50% coma and death.
6. A nurse assesses the client’s burn injury and determines that the client
sustained a partial-thickness superficial burn. Based on this
determination, which finding did the nurse note?
a. a wet, shiny, weeping wound
b. a dry wound surface
, NURS117 INTEGUMENTARY EXAM QUESTIONS
WITH ANSWERS GRADED A+
c. charring at the wound site
d. absence of wound sensation
A partial-thickness superficial burn appears wet, shiny, and weeping, or may
contain blisters. The wound blanches with pressure, is painful, and very
sensitive to touch or air currents. Charring would occur in a deep full-
thickness burn. Decreased or absence of wound sensation would occur in full-
thickness or deep full-thickness burns.
7. A nurse assesses the client’s burn injury and determines that the client
sustained a partial-thickness deep burn. Based on this determination,
which finding did the nurse note?
a. a wet, shiny, weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. total absence of wound sensation
A partial-thickness deep burn appears dry and may be red or white in
appearance. No blanching occurs and thrombosed vessels may be visible.
Decreased wound sensation will be present. Blisters and a wet shiny weeping
surface occur in partial-thickness superficial burns. Charring would occur in
deep full-thickness burns. Total absence of wound sensation would occur in
deep full-thickness burns.
8. On assessment of a child, the nurse notes the presence of white
patches on the child’s tongue and determines that they may be
indicative of candidiasis (thrush). The nurse understands that the
white patches of candidiasis (thrush):
a. adhere to the tongue even when scraped with tongue blade
b. cause the tongue to bleed continuously around the patch
c. produce a red circle in the center of the white lesion
d. will occur only in the tongue
Candidiasis, a fungal infection, adheres firmly to the tongue and/or mucous
membranes of the mouth and throat. Bleeding may occur after the trauma of
trying to remove the patches. A red circle on the skin may be associated with
other disorders such as Lyme disease but is not seen in candidiasis.
Candidiasis can occur on the oral mucous membranes as well as on the
tongue.
9. On assessment, a nurse notes a flat brown circular nevi on the skin of
a client that measures less than one centimeter. The client asks, “Is
this cancer?” The nurse makes which response to the client?
WITH ANSWERS GRADED A+
1. A nurse is caring for a burn client who has sustained thoracic burns
and smoke inhalation and is risk for impaired gas exchange. The nurse
avoids which action in caring for this client?
a. repositioning the client from side to side every 2 hours
b. maintaining the client in a supine position with the head of
the bed elevated
c. suctioning the airway as needed
d. providing humidified oxygen as prescribed
Aggressive pulmonary measures are used to prevent respiratory
complications in the client who has impaired gas exchange as a result of a
burn injury. These include turning and repositioning, positioning for comfort,
using humidified oxygen, providing incentive spirometry, and suctioning the
client on an as needed basis. The nurse would avoid maintaining the client in
one position. This will ultimately lead to atelectasis and possible pneumonia.
2. A client sustains a burn injury to the entire right arm, entire right leg,
and anterior thorax. According to the rule of nine’s the nurse
determines that what body percent was injured?
Answer: 45%
According to the Rule of Nine’s, the right arm is equal to 9% and the left arm
is equal to 9%. The right leg is equal to 18% and the left leg is equal to
18%. The anterior thorax is equal to 18% and the posterior thorax is equal
to 18%. The head is equal to 9% and the perineum is 1%. If the anterior
thorax (18%), entire right leg (18%), and entire right arm (9%) were
burned, according to the Rule of Nine’s, this would equal 45%.
3. A nurse assesses a burn injury and determines that the client
sustained a full-thickness fourth-degree burn if which of the following
is noted at the site of injury?
a. a wet shiny weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. blisters
In a full-thickness fourth-degree burn injury, charring is visible. Extremity
movement is limited and wound sensation is absent. Blisters and a wet shiny
,NURS117 INTEGUMENTARY EXAM QUESTIONS
WITH ANSWERS GRADED A+
weeping surface would be noted in a partial-thickness second-degree burn
injury. A dry wound surface would be noted in a full-thickness third-degree
burn injury.
4. A client is brought to the emergency room following a burn injury. In
assessment the nurse notes that the client’s eyebrow and nasal hairs
are singed. The nurse would identify this type of burn as:
a. thermal
b. electrical
c. radiation
d. chemical
Exposure to or contact with flames, hot liquids, or hot objects causes thermal
burns. Thermal burns are those sustained in residential fires, explosive
accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes
facial burns or singed eyebrow or nasal hairs, the victim likely experienced
the burn in an enclosed smoke filled space such as in a residential fire.
Electrical burns are caused by heat that is generated by the electrical energy
as it passes through the body. Radiation burns are caused by exposure to a
radioactive source. Chemical burns are caused by tissue contact with strong
acids, alkalis, or organic compounds.
5. A nurse assesses the carbon monoxide level of a client following a
burn injury and notes that the level is 8%. Based on this level, which
finding would the nurse expect to note during the assessment of the
client?
a. tachycardia
b. tachypnea
c. coma
d. impaired visual acuity
Clinical manifestations of carbon monoxide poisoning are related to the levels
of carbon monoxide saturation. A level between 5 to 10% would cause
impaired visual acuity; 11 to 20% flushing and headache; 21 to 30% nausea
and impaired dexterity; 31 to 40% vomiting, dizziness, and syncope; 41 to
50% tachypnea and tachycardia; and greater than 50% coma and death.
6. A nurse assesses the client’s burn injury and determines that the client
sustained a partial-thickness superficial burn. Based on this
determination, which finding did the nurse note?
a. a wet, shiny, weeping wound
b. a dry wound surface
, NURS117 INTEGUMENTARY EXAM QUESTIONS
WITH ANSWERS GRADED A+
c. charring at the wound site
d. absence of wound sensation
A partial-thickness superficial burn appears wet, shiny, and weeping, or may
contain blisters. The wound blanches with pressure, is painful, and very
sensitive to touch or air currents. Charring would occur in a deep full-
thickness burn. Decreased or absence of wound sensation would occur in full-
thickness or deep full-thickness burns.
7. A nurse assesses the client’s burn injury and determines that the client
sustained a partial-thickness deep burn. Based on this determination,
which finding did the nurse note?
a. a wet, shiny, weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. total absence of wound sensation
A partial-thickness deep burn appears dry and may be red or white in
appearance. No blanching occurs and thrombosed vessels may be visible.
Decreased wound sensation will be present. Blisters and a wet shiny weeping
surface occur in partial-thickness superficial burns. Charring would occur in
deep full-thickness burns. Total absence of wound sensation would occur in
deep full-thickness burns.
8. On assessment of a child, the nurse notes the presence of white
patches on the child’s tongue and determines that they may be
indicative of candidiasis (thrush). The nurse understands that the
white patches of candidiasis (thrush):
a. adhere to the tongue even when scraped with tongue blade
b. cause the tongue to bleed continuously around the patch
c. produce a red circle in the center of the white lesion
d. will occur only in the tongue
Candidiasis, a fungal infection, adheres firmly to the tongue and/or mucous
membranes of the mouth and throat. Bleeding may occur after the trauma of
trying to remove the patches. A red circle on the skin may be associated with
other disorders such as Lyme disease but is not seen in candidiasis.
Candidiasis can occur on the oral mucous membranes as well as on the
tongue.
9. On assessment, a nurse notes a flat brown circular nevi on the skin of
a client that measures less than one centimeter. The client asks, “Is
this cancer?” The nurse makes which response to the client?
