Nokea
Using the rule of nines, calculate the total body surface area (TBSA) burned. Fill in the blank. …………………….%
- A. 36%
- B. 45%
- C. 54%
- D. 63%
Correct Answer: C
Rationale: Using the rule of nines: chest (9%), abdomen (9%), back (18%), bilateral anterior arms (9% total, 4.5% each) = 9 + 9 + 18 + 9 = 45% TBSA.
You may also like to solve these questions
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply.
- A. Cleanse the affected area with isopropyl alcohol
- B. Apply zinc oxide to the affected area
- C. Use an incontinence pad instead of a brief
- D. Applying an extra incontinence brief to encapsulate the moisture
- E. Apply a transparent dressing to the affected area
Correct Answer: B, C
Rationale: Zinc oxide protects the skin, and incontinence pads reduce moisture exposure. Alcohol is too harsh, extra briefs trap moisture, and transparent dressings are not suitable for this condition.
The nurse has received a prescription for a high-potency topical corticosteroid lotion. The nurse should instruct the client to avoid applying the lotion to the client's
- A. feet
- B. face
- C. outer thigh
- D. abdomen
Correct Answer: B
Rationale: High-potency corticosteroids should not be applied to the face due to the risk of skin thinning and other side effects in this sensitive area.
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
- A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
- B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
- C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
- D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 3 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the clinical data, the nurse's immediate concern is the client's
- A. risk for infection
- B. thermoregulation
- C. airway patency
- D. fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit is the immediate concern due to significant fluid loss from extensive burns, risking hypovolemic shock.
The nurse is performing a physical assessment on a client who has a round, non-tender nodule on the left wrist. It would be appropriate for the nurse to identify this as a
- A. janeway lesion
- B. bouchard node
- C. ganglion cyst
- D. pilar cyst
Correct Answer: C
Rationale: A round, non-tender nodule on the wrist is characteristic of a ganglion cyst, a benign fluid-filled sac.