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A patient received deep partial-thickness burns to the anterior trunk, perineum, and left posterior and anterior arm. Using the "Rule of nines," what is the percent of total body surface area (TBSA) that was burned?

18%

36%

40%

28%

Answer and Explanation

The Correct Answer is D

Adding these percentages together:

Anterior trunk: 18%
Perineum: 1%
Left anterior arm: 4.5%
Left posterior arm: 4.5%

Total = 18% + 1% + 4.5% + 4.5% = 28%

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Correct Answer is B

Explanation

Choice A rationale: While impaired tissue perfusion can affect activity tolerance, addressing the underlying perfusion issue takes precedence.
Choice B rationale: Varicose veins with ulcerations and lower extremity edema suggest impaired tissue perfusion. The compromised blood flow can lead to poor oxygenation and nutrient delivery to tissues, increasing the risk of ulceration and delayed wound healing.
Choice C rationale: Impaired tissue perfusion contributes to impaired skin integrity, but it is not the primary issue.
Choice D rationale: While varicose veins can impact body image, addressing impaired tissue perfusion is more critical for the client's overall well-being.

A. Massage bony prominences to promote circulation. B. Reposition the client every 3 hr. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

Correct Answer is B

Explanation

Choice A rationale: older adults have thin skin hence massaging bony prominences increases the risk of skin breakdown and pressure ulcers formation.
Choice B rationale: frequent client repositioning every 2-3 hourly is one of the mitigations used to prevent skin breakdown especially in older adults who are bedridden. It aids in the distribution of pressure on bony prominences and also relieves the pressure on the areas at risk and maintains muscle mass and tissue integrity.
Choice C rationale: a high protein diet is important for healthy skin formation. However, in this case frequent repositioning is more crucial for maintaining skin integrity in older adults.
Choice D rationale: cornstarch application can be used to prevent skin damage from friction. However, this is not as important as frequent repositioning.

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A patient received deep partial-thickness burns to the anterior trunk, perineum, and left posterior and anterior arm. Using the "Rule of nines," what is the percent of total body surface area (TBSA) that was burned?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is B

Explanation

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