An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED. with full thickness burns on both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?
18%
27%
36%
45%
The Correct Answer is C
Choice A: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.
Choice B: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.
Choice C: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.
Choice D: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4"]
Explanation
Step 1 is to convert the child’s weight from pounds to kilograms.
44 pounds ÷ 2.2 = 20 kilograms.
Result at each step = 20 kilograms.
Step 2 is to calculate the total dosage of furosemide in milligrams.
2 mg × 20 kg = 40 mg.
Result at each step = 40 mg.
Step 3 is to determine the volume of medication to administer in milliliters.
40 mg ÷ 10 mg/mL = 4 mL.
Result at each step = 4 mL.
The nurse should administer 4 mL.
Correct Answer is A
Explanation
Choice A: Obtain a capillary glucose level. This is the first action that the nurse should do, as it can diagnose hypoglycemia, which is a low blood sugar level that can cause jitteriness and tachypnea in newborns. Hypoglycemia can be caused by maternal diabetes, prematurity, infection, or delayed feeding. The nurse should check the glucose level using a heel stick and a glucometer.
Choice B: Feed 30 mL of 10% dextrose in water. This is not the first action that the nurse should do, as it may not be appropriate for all newborns with jitteriness and tachypnea. Feeding 10% dextrose in water can raise the blood sugar level, but it may also cause rebound hypoglycemia or fluid overload. The nurse should feed only after confirming hypoglycemia and obtaining a healthcare provider's order.
Choice C: Wrap tightly in a blanket. This is not the first action that the nurse should do, as it may not address the underlying cause of jitteriness and tachypnea in newborns. Wrapping tightly in a blanket can prevent heat loss and conserve energy, but it may also impair breathing or circulation. The nurse should wrap only after ruling out other causes of jitteriness and tachypnea.
Choice D: Encourage the mother to breastfeed. This is not the first action that the nurse should do, as it may not be feasible or effective for all newborns with jitteriness and tachypnea. Breastfeeding can provide nutrition and bonding for newborns, but it may also be difficult or contraindicated for some newborns with respiratory distress or infection. The nurse should encourage breastfeeding only after assessing and stabilizing the newborn's condition.
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