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 C
Explanation
A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.
B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.
C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.
D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.
Correct Answer is D
Explanation
A. Gently cleanse the wounds with warm soapy water
Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.
B. Remove blistered skin and cover with a dry dressing
Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.
C. Apply saline-soaked wet-to-dry dressings
Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.
D. Cover with a clean dry sheet to prevent hypothermia
Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.
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