A patient experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED. with partial-thickness burns on the anterior surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

18%.

45%.

9%.

36%.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct answer. According to the rule of nines, each leg accounts for 18% of the total body surface area, and the anterior surface of each leg accounts for half of that, or 9%. Therefore, the patient has partial-thickness burns on 9% + 9% = 18% of the body surface area.

Choice B reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, as well as the head and neck, which is not given in the question.

Choice C reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior surface of only one leg, which is not given in the question.

Choice D reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, which is not given in the question.

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Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

A. Recommend the use of support stockings to enhance venous return B. Ensure the client receives frequent small meals containing complete proteins C. Evaluate patency of the AV graft for resumption of hemodialysis D. Instruct the client to continue to follow the prescribed rigid fluid restriction amounts

Correct Answer is B

Explanation

Choice A reason: Support stockings may help with peripheral edema, but they are not the priority intervention for this client. The client's low serum albumin level indicates malnutrition and increased risk of infection and poor wound healing.

Choice C reason: Evaluating patency of the AV graft is not the priority intervention for this client because the client is receiving peritoneal dialysis, not hemodialysis. The AV graft may be used in the future if peritoneal dialysis fails, but it is not an immediate concern.

Choice D reason: Instructing the client to follow fluid restriction amounts is important for peritoneal dialysis patients, but it is not the priority intervention for this client. The client's low serum albumin level indicates that fluid restriction alone is not sufficient to manage fluid balance and prevent edema.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

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The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate attention?

The nurse is preparing a dose of 10 mg of teriparatide. The medication is labeled 760 mcg/2.4 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to ask in the assessment of this client?