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A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

36%

18%

27%

Answer and Explanation

The Correct Answer is C

Left arm (entire): 9%

Anterior chest: 18%

Total: 9% + 18% = 27%

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Correct Answer is A

Explanation

A. Hyperkalemia: During the emergent phase, massive cell injury causes potassium to leak into the extracellular space, raising serum K+ levels.

B. Hypokalemia: More common later in the fluid resuscitation or diuretic phase.

C. Hypernatremia: Sodium is often lost into burned tissues or with fluid shifts; hyponatremia may be seen early.

D. Hypocalcemia: While possible, especially if blood products are given, hyperkalemia is more prominent early.

A. Maintain adequate IV hydration B. Administer broad-spectrum antibiotics C. Give IV potassium chloride D. Prepare intramuscular pain medications

Correct Answer is A

Explanation

A. Maintain adequate IV hydration: The first priority in major burns is fluid resuscitation due to massive fluid shifts and risk of hypovolemic shock.

B. Administer broad-spectrum antibiotics: Not a priority during the initial resuscitative phase. Infection control comes later unless signs of sepsis appear.

C. Give IV potassium chloride: Burn patients often experience hyperkalemia initially due to cell lysis; potassium is not given early.

D. Prepare intramuscular pain medications: IM route is avoided due to poor perfusion and risk of inadequate absorption in burn patients.

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A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

Correct Answer is A

Explanation

A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

Correct Answer is A

Explanation

A nurse is preparing to administer a large dose of prescribed opioid analgesic and light sedation for a dressing change for a client with significant burn injuries. The nurse is aware that which of the following is part of preparing for the opioid analgesic and sedative administration?

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A nurse is teaching a client diagnosed with chronic kidney disease (CKD) about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)

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