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 A
Explanation
Choice A is correct because the nurse's priority is to provide comfort and dignity to the dying patient. Pain management is an essential aspect of end-of-life care.
Choice B is incorrect because updating the nurse manager is not a priority action. The nurse manager can be informed later, after the patient's needs are met.
Choice C is incorrect because conveying the patient's status to the chaplain is not a priority action. The chaplain can be contacted later, after the patient's needs are met. The chaplain may also need the consent of the patient or the family before providing spiritual support.
Choice D is incorrect because documenting the impending signs of death is not a priority action. Documentation can be done later, after the patient's needs are met. Documentation is important, but not as important as providing comfort and dignity to the dying patient.
Correct Answer is C
Explanation
Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.
Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.
Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.
Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.
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