A client has burns to the entire back, anterior and posterior surfaces of both legs, and the left arm.
Using the Rule of Nines, what percentage of total body surface area is burned?

Prioritizing interventions for autonomic dysreflexia in quadriplegic clients requires understanding the physiological response to noxious stimuli below the injury level. Critical thinking is applied to determine the most immediate action to lower dangerous hypertensive levels and prevent intracranial hemorrhage or seizures.

Choice A rationale

Nitrates are used to manage severe hypertension in autonomic dysreflexia, but pharmacological intervention is not the first step. Non-pharmacological measures to reduce blood pressure should be attempted immediately before administering medications to the client to ensure safety.

Choice B rationale

Assessing for bladder distention is vital because it is the most common trigger for autonomic dysreflexia. However, physiological stabilization via positioning must occur before or simultaneously with the search for the underlying cause to prevent immediate vascular complications.

Choice C rationale

Monitoring the heart rate is necessary as bradycardia often accompanies the hypertensive surge in autonomic dysreflexia. While important for assessment, obtaining vital signs does not actively lower the blood pressure or address the immediate risk of a stroke.

Choice D rationale

Placing the client in a high-Fowler's position is the priority action because it utilizes gravity to cause orthostatic pooling of blood in the lower extremities. This immediate intervention helps decrease the dangerously high blood pressure and reduces intracranial pressure..

The nurse must utilize knowledge of thoracic drainage mechanics and equipment troubleshooting. A three-chamber system requires consistent suction to maintain negative pleural pressure. Identifying the cause of suction failure involves systematic assessment of the external vacuum source and tube integrity.

Choice A rationale

Suction control chambers in wet systems require active external suction to function. Bubbling indicates vacuum application. Verifying the regulator is on ensures the system has the mechanical force necessary to maintain the ordered negative pressure for lung re-expansion.

Choice B rationale

Milking or stripping chest tubes creates high levels of negative pressure that can damage delicate lung tissue. This practice is generally contraindicated unless specifically ordered by a surgeon, as it increases the risk of pleural trauma and tension pneumothorax.

Choice C rationale

Absence of bubbling in the suction control chamber of a wet system is an abnormal finding. It signifies a lack of active suctioning. The nurse cannot ignore this, as effective pleural drainage depends on continuous atmospheric pressure regulation.

Choice D rationale

While water levels dictate suction intensity, adding water will not resolve a lack of bubbling if the suction source is off. Bubbling is caused by air passing through water via the suction regulator, not the volume itself.