An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED. with full thickness burns on both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?
18%
27%
36%
45%
The Correct Answer is C
Choice A: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.
Choice B: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.
Choice C: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.
Choice D: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C is correct because providing supplemental oxygen is the first action that the nurse should take for a client who has a suspected pulmonary embolus. A pulmonary embolus is a life-threatening condition that occurs when a blood clot travels to the lungs and blocks the blood flow, causing hypoxia and respiratory distress. The nurse should administer oxygen to improve the client's oxygenation and prevent further complications.
Choice A is incorrect because notifying the healthcare provider is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The nurse should notify the healthcare provider after providing supplemental oxygen and assessing the client's vital signs and symptoms.
Choice B is incorrect because preparing a continuous heparin infusion per protocol is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. Heparin is an anticoagulant that can prevent further clot formation and reduce the risk of recurrence, but it does not dissolve existing clots or improve oxygenation. The nurse should prepare a heparin infusion after obtaining a prescription from the healthcare provider and confirming the diagnosis with diagnostic tests.
Choice D is incorrect because bringing the emergency crash cart to the bedside is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The emergency crash cart contains equipment and medications that can be used in case of cardiac arrest or other emergencies, but it does not address the immediate need of oxygenation. The nurse should bring the emergency crash cart to the bedside after providing supplemental oxygen and assessing the client's condition.
Correct Answer is B
Explanation
Choice A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.
Choice B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.
Choice C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.
Choice D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.
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