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 D
Explanation
A. Dyspnea on exertion: Dyspnea on exertion is a common symptom in clients with heart failure and may indicate worsening heart function. While it warrants monitoring and potential intervention, it is not as urgent as rapid weight gain.
B. Increased urination: Increased urination may be expected with the use of diuretics, as they promote the excretion of excess fluid from the body. This finding is not typically concerning unless accompanied by other symptoms.
C. Weight gain of 2 pounds in a week: A weight gain of 2 pounds in a week may indicate fluid retention, but it is not as concerning as a rapid weight gain over a shorter period.
D. Weight gain of 3 pounds in 24 hours: A rapid weight gain of 3 pounds in 24 hours is significant and may indicate fluid overload, potentially leading to exacerbation of heart failure symptoms. It should be reported promptly to the healthcare provider for further evaluation and management.
Correct Answer is C
Explanation
A. A diet high in potassium: A high-potassium diet can actually help lower blood pressure and is often recommended for hypertensive patients.
B. Taking benazepril: Benazepril is an ACE inhibitor used to treat hypertension, so it is not a risk factor for developing high blood pressure.
C. Obstructive sleep apnea (OSA): OSA is a significant risk factor for the development of hypertension. The repeated episodes of apnea during sleep can lead to increased sympathetic nervous system activity and elevated blood pressure.
D. High-density lipoprotein (HDL) level of 70 mg/dL: A high HDL level is generally considered protective against cardiovascular diseases, including hypertension.
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