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An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the rule of nines assesses the burn as

A.

32

B.

20

C.

55

D.

22

Answer and Explanation

The Correct Answer is A

The "Rule of Nines" is used to estimate the total body surface area (TBSA) affected by burns in adults.

  • Entire right leg: 9% (front) + 9% (back) = 18%
  • Front of the right arm: The entire arm is 9%, so the front half would be approximately 4.5%.
  • One half of the front torso: The entire front torso (chest and abdomen) is 18%. One half of the front torso is 18% / 2 = 9%.
  • Adding these percentages:

18% (right leg) + 4.5% (front right arm) + 9% (half front torso) = 31.5%.

  • This approximated by 32%.


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Related Questions

Correct Answer is C

Explanation

A. Continue to monitor the client as this is an expected finding: Absence of bubbling in the suction control chamber can indicate that the suction is not functioning properly. It is not an expected finding. Further assessment is necessary to identify any issues with the system.

B. Add more water to the suction control chamber of the drainage system: Adding water may be necessary to ensure the correct water level in the suction chamber, but it won't address the underlying issue if the suction regulator is off or the system has a leak.

C. Verify that the suction regulator is on and check the tubing for leaks: No bubbling in the suction control chamber often points to a problem with the suction regulator or a potential leak in the system. Verifying the suction settings and checking for leaks is the most appropriate.

D. Milk the chest tube and dislodge any clots in the tubing that are occluding it: Milking the chest tube may be necessary if there is a blockage, but it would not address the issue of no bubbling which is more likely related to suction malfunction or tubing issues rather than a clot.

Correct Answer is A

Explanation

The "Rule of Nines" is used to estimate the total body surface area (TBSA) affected by burns in adults.

  • Entire right leg: 9% (front) + 9% (back) = 18%
  • Front of the right arm: The entire arm is 9%, so the front half would be approximately 4.5%.
  • One half of the front torso: The entire front torso (chest and abdomen) is 18%. One half of the front torso is 18% / 2 = 9%.
  • Adding these percentages:

18% (right leg) + 4.5% (front right arm) + 9% (half front torso) = 31.5%.

  • This approximated by 32%.

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