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 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.

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