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 C
Explanation
Choice A reason: Measuring abdominal girth is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be useful for monitoring fluid status and abdominal distension.
Choice B reason: Assessing perineal area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be important for maintaining hygiene and preventing infection.
Choice D reason: Palpating flank area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be helpful for detecting kidney tenderness or enlargement.
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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