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:
-
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%
-
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%
-
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 D
Explanation
Choice A Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client is hyperventilating and losing too much carbon dioxide.
Choice B Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low bicarbonate level, indicating that the client has an excess of metabolic acids or a loss of base.
Choice C Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high bicarbonate level, indicating that the client has an excess of base or a loss of metabolic acids.
Choice D Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client is hypoventilating and retaining too much carbon dioxide.
