A nurse is caring for a client who has burns on both arms, chest, abdomen and upper and lower back. Utilizing the Rule of Nines, the nurse estimates that the extent of the client's burns is which of the following percentages?
18%
44%
36%
54%
The Correct Answer is D
A. 18% is inaccurate
B. 44% is inaccurate
C. 36% is inaccurate
D. According to the Rule of Nines:
Each arm is typically assigned 9% (4.5% for each arm). The chest and abdomen together are assigned 18%.
The upper back is assigned 9%.
The lower back is assigned 9%.
Each leg is typically assigned 18% (9% for each leg). Adding these percentages together for the described burns:
9% (each arm) + 18% (chest and abdomen) + 9% (upper back) + 9% (lower back) = 54%
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Docusate Sodium (Colace) is a stool softener and is not contraindicated in chronic renal disease.
B. Acetaminophen (Tylenol) is generally safe for use in chronic renal disease, but dosing adjustments may be necessary based on renal function.
C. Meperidine (Demerol) is contraindicated in clients with chronic renal disease because its metabolites can accumulate in renal impairment, leading to neurotoxicity and seizures. It is often replaced with alternative opioid analgesics like morphine or fentanyl in these patients.
D. Atorvastatin (Lipitor) is a statin medication used to lower cholesterol levels and is generally safe in chronic renal disease, although dosing adjustments may be needed depending on the severity of renal impairment.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.
No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.
Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.
No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.
Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.
Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.
Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.
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