NU 272: Tissue Integrity Questions With Complete Solutions
Following a serious thermal burn, which complication will the nurse take action to prevent first?
Tissue hypoxia
Infection
Renal failure
Hypovolemia -correct answer 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 -correct answer 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
, NU 272: Tissue Integrity Questions With Complete Solutions
Applying continuous-compression wraps
Wearing clothing to protect the burn from the sun
Maintaining wound care irrigation -correct answer 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
Moderate to severe pain
Urine output of 70 ml the first hour
Hoarseness of the voice -correct answer Hoarseness of the voice
Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate
intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss,
leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine
output is adequate.
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would
cause the nurse the most concern?
BUN: 28 mg/dL
K+: 5.0 mEq/L
Na+: 145 mEq/L
Ca: 9 mg/dL -correct answer BUN: 28 mg/dL
The elevated BUN would cause the nurse the most concern (normal BUN is 7-20 mg/dL). The nurse
should report decreased urine output or increased BUN and creatinine values to the physician. These
Following a serious thermal burn, which complication will the nurse take action to prevent first?
Tissue hypoxia
Infection
Renal failure
Hypovolemia -correct answer 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 -correct answer 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
, NU 272: Tissue Integrity Questions With Complete Solutions
Applying continuous-compression wraps
Wearing clothing to protect the burn from the sun
Maintaining wound care irrigation -correct answer 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
Moderate to severe pain
Urine output of 70 ml the first hour
Hoarseness of the voice -correct answer Hoarseness of the voice
Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate
intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss,
leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine
output is adequate.
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would
cause the nurse the most concern?
BUN: 28 mg/dL
K+: 5.0 mEq/L
Na+: 145 mEq/L
Ca: 9 mg/dL -correct answer BUN: 28 mg/dL
The elevated BUN would cause the nurse the most concern (normal BUN is 7-20 mg/dL). The nurse
should report decreased urine output or increased BUN and creatinine values to the physician. These
