Related Questions

Correct Answer is A

Explanation

Choice A Reason: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:

  • Front of one leg = 9%
  • Back of one leg = 9%
  • Front of one arm = 4.5%
  • Back of one arm = 4.5%

Now for the calculation:

  1. Both legs (front and back):

    • Front of both legs = 9% × 2 = 18%
    • Back of both legs = 9% × 2 = 18%
    • Total for both legs = 18% + 18% = 36%
  2. Both arms (front and back):

    • Front of both arms = 4.5% × 2 = 9%
    • Back of both arms = 4.5% × 2 = 9%
    • Total for both arms = 9% + 9% = 18%
  3. Total TBSA:

    • Legs (36%) + Arms (18%) = 54%

The nurse should document burns to 54% of the client's total body surface area (TBSA).

Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because fluid overload is a condition of excess fluid volume in the body. A client who has fluid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.

Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood flow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.

Choice C Reason: This is correct because hypovolemia is a condition of low fluid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.

Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.

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