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%.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Encourage rest until the analgesic becomes effective. This is not the best intervention, as it does not address the client's preference or comfort level. The analgesic may take some time to relieve the pain, and forcing the client to lie down may increase the pressure on the pancreas and worsen the pain.
Choice B: Raise head of bed until at a 90 degree angle. This is not the best intervention, as it does not address the client's preference or comfort level. Raising the head of bed may help reduce abdominal distension and improve breathing, but it may not relieve the pain as much as leaning forward.
Choice C: Place bed in a reverse Trendelenburg position. This is not the best intervention, as it does not address the client's preference or comfort level. Placing the bed in a reverse Trendelenburg position may help shift the abdominal organs away from the pancreas and reduce inflammation, but it may not relieve the pain as much as leaning forward.
Choice D: Position bedside table so the client can lean across it. This is the best intervention, as it addresses the client's preference and comfort level. Leaning forward may help decrease the tension on the pancreas and relieve the pain. The bedside table can provide support and stability for the client while sitting up.
Correct Answer is B
Explanation
Choice B is correct because assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.
Choice A is incorrect because ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.
Choice C is incorrect because assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.
Choice D is incorrect because assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.
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