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A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

36%

18%

27%

Answer and Explanation

The Correct Answer is C

Left arm (entire): 9%

Anterior chest: 18%

Total: 9% + 18% = 27%

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Correct Answer is C

Explanation

A. Auscultate the antecubital fossa using a Doppler stethoscope: The graft is located in the forearm, not the antecubital fossa.

B. Measure the client's blood pressure to ensure it is higher in the left arm than the right: This does not assess AV graft patency and blood pressure should be avoided in the arm with a graft.

C. Auscultate the site for a bruit: The presence of a bruit and thrill indicates blood flow through the graft, confirming patency.

D. Check the brachial and radial pulses of the left arm simultaneously: While peripheral pulses can offer some insight, they do not directly confirm graft patency.

A. Ensure NPO status B. Administer diphenhydramine (Benadryl) prior to procedure. C. Obtain coagulation studies D. Verify informed consent E. Collect a urine specimen prior to procedure

Correct Answer is ["A","C","D","E"]

Explanation

A. Ensure NPO status: The client is kept NPO before the biopsy to reduce the risk of aspiration if sedation is used.

B. Administer diphenhydramine (Benadryl) prior to procedure: This is not routine for kidney biopsy unless the client has allergies or specific indications.

C. Obtain coagulation studies: Important to assess for bleeding risk because kidney biopsies have a high bleeding potential.

D. Verify informed consent: This is essential before any invasive procedure.

E. Collect a urine specimen prior to procedure: A pre-procedure urine sample is collected for baseline comparison.

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A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Correct Answer is C

Explanation

A nurse is preparing a client for the operating room Exhibits A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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A nurse is preparing to administer a large dose of prescribed opioid analgesic and light sedation for a dressing change for a client with significant burn injuries. The nurse is aware that which of the following is part of preparing for the opioid analgesic and sedative administration?