A nurse is caring for a client who has burns on both arms, chest, abdomen and upper and lower back. Utilizing the Rule of Nines, the nurse estimates that the extent of the client's burns is which of the following percentages?
18%
44%
36%
54%
The Correct Answer is D
A. 18% is inaccurate
B. 44% is inaccurate
C. 36% is inaccurate
D. According to the Rule of Nines:
Each arm is typically assigned 9% (4.5% for each arm). The chest and abdomen together are assigned 18%.
The upper back is assigned 9%.
The lower back is assigned 9%.
Each leg is typically assigned 18% (9% for each leg). Adding these percentages together for the described burns:
9% (each arm) + 18% (chest and abdomen) + 9% (upper back) + 9% (lower back) = 54%
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Prolonged P-R interval: A prolonged P-R interval may indicate an atrioventricular (AV) block or conduction delay, but it is not specifically associated with hyperkalemia.
B. Peaked T waves: Peaked T waves are a classic EKG finding in hyperkalemia. Hyperkalemia can affect cardiac repolarization, leading to tall, peaked T waves on the EKG.
C. Elevated ST segment: An elevated ST segment may indicate myocardial injury or ischemia but is not typically associated with hyperkalemia.
D. Inverted P wave: An inverted P wave may indicate atrial enlargement or conduction abnormalities but is not specifically associated with hyperkalemia.
Correct Answer is C
Explanation
A. Reports of joint pain: Joint pain is more indicative of musculoskeletal issues rather than chronic renal disease. While joint pain can occur in some types of kidney disease, progressive edema is a more specific symptom.
B. Increase in appetite: An increase in appetite is not typically associated with chronic renal disease. Instead, clients with kidney disease may experience a decrease in appetite due to various factors such as nausea, vomiting, and changes in taste.
C. Progressive edema: Progressive edema, especially in the lower extremities and around the eyes (periorbital edema), can be a significant indicator of declining kidney function. It results from fluid retention due to impaired kidney filtration.
D. Recent increase in thirst: While increased thirst can be a symptom of chronic renal disease, it is not as specific as progressive edema. Increased thirst may occur due to other conditions or factors such as diabetes mellitus or dehydration.
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