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)?

Choice A reason: This is incorrect because providing a diet low in phosphorus is not indicated for a client with cirrhosis of the liver. Phosphorus restriction is more relevant for clients with renal failure, not liver failure.

Choice B reason: This is correct because noting signs of swelling and edema is an essential intervention for a client with cirrhosis of the liver. Swelling and edema are signs of fluid retention and portal hypertension, which are common complications of liver disease.

Choice C reason: This is incorrect because increasing oral fluid intake to 1,500 mL daily is not advisable for a client with cirrhosis of the liver. Fluid restriction may be necessary to prevent fluid overload and ascites, which are common complications of liver disease.

Choice D reason: This is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver. Abdominal girth measurement can indicate the presence and severity of ascites, which is a common complication of liver disease.

Choice E reason: This is correct because reporting serum albumin and globulin levels is a vital intervention for a client with cirrhosis of the liver. Serum albumin and globulin levels can reflect the liver's synthetic function and indicate the extent of liver damage.

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Administering PRN pain medication prior to transport is not the most important action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.

Choice C reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

Choice D reason: This is the correct answer because keeping chest tube container below the site of insertion is the most important action for the nurse to take. Chest tube container is a device that collects air or fluid from the chest tube and maintains negative pressure in the pleural space or mediastinum. Keeping chest tube container below the site of insertion can prevent backflow of air or fluid into the chest cavity and maintain adequate drainage. If the chest tube container is raised above the site of insertion, it can cause tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and heart.