A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of Your injury What percentage of body surface area should the nurse estimate the client has burned?

Answer and Explanation

The Correct Answer is ["54"]

Rationale: This is because according to the rule of nines, the lower limbs anteriorly and posteriorly will account for 18% each, and the back accounting for 18%

So, the TBSA will be, (18+18+18) =54%

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Correct Answer is A

Explanation

Choice A rationale: Basal cell carcinoma commonly presents as a small, translucent papule with rolled borders. It may have a pearly or shiny appearance and often develops on sun-exposed areas, such as the nose.
Choice B rationale: This description is more characteristic of melanoma, not basal cell carcinoma.
Choice C rationale: This description may be more indicative of squamous cell carcinoma.
Choice D rationale: This description does not align with the typical presentation of basal cell carcinoma.

A. Massage bony prominences to promote circulation. B. Reposition the client every 3 hr. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

Correct Answer is B

Explanation

Choice A rationale: older adults have thin skin hence massaging bony prominences increases the risk of skin breakdown and pressure ulcers formation.
Choice B rationale: frequent client repositioning every 2-3 hourly is one of the mitigations used to prevent skin breakdown especially in older adults who are bedridden. It aids in the distribution of pressure on bony prominences and also relieves the pressure on the areas at risk and maintains muscle mass and tissue integrity.
Choice C rationale: a high protein diet is important for healthy skin formation. However, in this case frequent repositioning is more crucial for maintaining skin integrity in older adults.
Choice D rationale: cornstarch application can be used to prevent skin damage from friction. However, this is not as important as frequent repositioning.

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A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of Your injury What percentage of body surface area should the nurse estimate the client has burned?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is B

Explanation

A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fl over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr?

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A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover wound?

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A nurse is assessing a client who has viral rhinitis and a history of herpes simplex virus type HSV-lesions. The nurse should assess which o following areas of the body for the recurrence of HSV-1 lesions?

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?