A patient experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED. with partial-thickness burns on the anterior surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?
18%.
45%.
9%.
36%.
The Correct Answer is A
Choice A reason: This is the correct answer. According to the rule of nines, each leg accounts for 18% of the total body surface area, and the anterior surface of each leg accounts for half of that, or 9%. Therefore, the patient has partial-thickness burns on 9% + 9% = 18% of the body surface area.
Choice B reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, as well as the head and neck, which is not given in the question.
Choice C reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior surface of only one leg, which is not given in the question.
Choice D reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, which is not given in the question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Increasing oral fluids may help with hydration, but it will not reduce skin flushing caused by lisinopril. Lisinopril is an angiotensin-converting enzyme (ACE. inhibitor that dilates blood vessels and lowers blood pressure. Flushing occurs due to increased blood flow to the skin.
Choice B: Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces chest pain caused by angina. It is not indicated for skin flushing caused by lisinopril. Moreover, nitroglycerin can lower blood pressure further and cause hypotension, headache, dizziness, and fainting.
Choice C: Going to an emergency department is not necessary for skin flushing caused by lisinopril. Flushing is not a sign of an allergic reaction or anaphylaxis, which would require immediate medical attention. Flushing is also not a symptom of a heart attack or stroke, which would present with other signs such as chest pain, shortness of breath, arm numbness, or slurred speech.
Choice D: Reassuring the client that facial flushing is a common side effect of lisinopril is the best action for the nurse to take. Flushing is not harmful or dangerous, and it usually subsides within a few hours. The nurse should explain the mechanism of action of lisinopril and its benefits for lowering blood pressure and preventing angina. The nurse should also advise the client to monitor his blood pressure regularly and report any signs of hypotension, such as dizziness, lightheadedness, or fainting.
Correct Answer is B
Explanation
Choice A: Assigning the UAP to provide care for another client and assume full care of the client is not an action that the nurse should take, as this is unnecessary and inefficient. The UAP can safely assist the client with influenza if they follow proper infection control measures. This is an incorrect choice.
Choice B: Reviewing the need for the UAP to wear a face mask while in close contact with the client is an action that the nurse should take, as this can protect the UAP and others from droplet transmission of influenza. This is a standard precaution that should be reinforced by the nurse. Therefore, this is the correct choice.
Choice C: Instructing the UAP to apply a fitted respirator mask before entering the client's room is not an action that the nurse should take, as this is not indicated for a client with influenza. A respirator mask is required for airborne transmission, not droplet transmission. This is another incorrect choice.
Choice D: Directing the UAP to notify the nurse of any changes in the client's respiratory status is not an action that the nurse should take, as this is a general instruction that does not address the specific issue of infection control. This is another incorrect choice.
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