The nurse is caring for an adult with a burn injury. The following parts of the patient's body were burned: anterior and posterior right arm, posterior trunk. and posterior right leg. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) percentage that is involved.
63% TBSA
45% TBSA
36% TBSA
27% TBSA
The Correct Answer is C
A. 63% TBSA
This value is too high based on the Rule of Nines calculation.
B. 45% TBSA
This overestimates the burn area.
C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:
- Entire right arm (anterior + posterior): 9%
- Posterior trunk: 18%
- Posterior right leg: 9%
- Total TBSA = 9% + 18% + 9% = 36%
D. 27% TBSA
This underestimates the affected areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Parkland Formula:
Total fluid requirement (ml)=4×Body weight (kg)×Total body surface area burned (%TBSA)
= 4×70×70
=19,600mL (total for 24 hours)
Fluids in first 8 hours: 19,600mL÷2
=9,800mL
Correct Answer is ["A","C","D"]
Explanation
A. Administer each unit of blood over 3–4 hours
Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.
B. Anticipate an order for acetaminophen
Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.
C. Anticipate an order for furosemide administration
Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.
D. Assess for signs and symptoms of fluid overload
CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.
E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion
FFP is given for coagulation disorders, not for treating anemia in a GI bleed.
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