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A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.
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A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Scatter rugs are present in the kitchen,
- B. Handrails are present in the bathroom.
- C. Electrical cords are placed along the walls.
- D. Uses a microwave for cooking.
Correct Answer: A
Rationale: Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment. Handrails provide support and help prevent falls, making them a safety feature, not a risk. Electrical cords placed along walls reduce tripping hazards. A microwave is generally safer than a stove, reducing the risk of burns and fires.
A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
- A. Stop the infusion of blood,
- B. Inform the provider.
- C. Obtain a urine specimen.
- D. Notify the laboratory.
Correct Answer: A
Rationale: Symptoms suggest an acute hemolytic transfusion reaction, a life-threatening emergency. Stopping the transfusion immediately is critical to prevent further reaction and hemolysis.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. 2 hr after obtaining blood from the blood bank
- B. When the client states he is ready to start the infusion
- C. As soon as the nurse can prepare the client and the administration set
- D. when the client has finished eating lunch
Correct Answer: C
Rationale: Blood products should be infused as soon as possible after preparation, ideally within 30 minutes, to reduce bacterial contamination risk and ensure efficacy.
A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.