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 C
Explanation
Choice A Reason: This is incorrect because right ventricular failure would cause an increase in right atrial pressure and right ventricular end-diastolic pressure, but not in PAWP, which reflects left atrial pressure and left ventricular end- diastolic pressure.
Choice B Reason: This is incorrect because fluid volume deficit would cause a decrease in PAWP, as there would be less blood volume in the pulmonary circulation.
Choice C Reason: This is correct because mitral regurgitation would cause an increase in PAWP, as the blood would back up into the left atrium and pulmonary veins due to the incompetent mitral valve.
Choice D Reason: This is incorrect because afterload reduction would cause a decrease in PAWP, as there would be less resistance to the left ventricular ejection and less blood volume in the pulmonary circulation.

