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

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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Correct Answer is A

Explanation

A. Test the drainage for glucose: Clear drainage from the nose following a basal skull fracture may be cerebrospinal fluid (CSF). The nurse should first test the drainage for glucose, as CSF contains glucose, which can confirm the presence of CSF.

B. Ask the client to blow his nose: Asking the client to blow their nose could increase the pressure in the skull and worsen the leakage of CSF, potentially causing more harm. This should be avoided in this situation.

C. Suction the nostril: Suctioning the nostril could increase the risk of further injury to the skull or brain, especially if CSF is leaking. The focus should be on confirming the presence of CSF, not suctioning the nostril.

D. Notify the physician: While notifying the physician is important, confirming whether the drainage is CSF first will guide the physician in making a more informed decision. Testing for glucose is the immediate action to confirm whether the fluid is CSF.

A. Airway protection B. Stabilizing cardiac arrhythmias C. Decreasing intracranial pressure D. Preventing musculoskeletal disability

Correct Answer is A

Explanation

A. Airway protection: In multiple system trauma, the priority focus of care is airway protection. Ensuring that the airway is open and that the client is receiving adequate oxygenation is the most critical step to prevent hypoxia, which can lead to further complications and death.

B. Stabilizing cardiac arrhythmias: While cardiac arrhythmias may need to be addressed, they are not the immediate priority in the trauma setting. Ensuring the airway is secure and oxygenation is maintained is more critical before addressing arrhythmias.

C. Decreasing intracranial pressure: While controlling intracranial pressure is important in trauma cases involving head injury, airway protection is the first priority. Airway management is critical to prevent hypoxia, which could worsen intracranial pressure.

D. Preventing musculoskeletal disability: Preventing musculoskeletal disability is important but is not the first priority. Stabilizing the airway is the immediate action. Musculoskeletal issues will be addressed later in the care process.

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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

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Correct Answer is A

Explanation

Calculate the total intravenous fluids infused in 24 hrs for a 147.4-lb client with a 31.5% TBSA burn and receiving insulin 5 units/hr. The concentration of insulin is 100 units in 100 mL normal saline.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid-base imbalances?

A nurse is caring for a client who has symptomatic sinus bradycardia. The Atropine was given but was not successful. Which one of the following is the next intervention?

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is caring for a client who is scheduled to receive heparin 3,800 units subcutaneously. Available is heparin 5,000 units/mL How many ml. should the nurse administer? (Round the answer to the nearest tenth.)