The nurse is caring for an adult with a burn injury. The following parts of the patient's body were burned: anterior and posterior right arm, posterior trunk. and posterior right leg. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) percentage that is involved.
63% TBSA
45% TBSA
36% TBSA
27% TBSA
The Correct Answer is C
A. 63% TBSA
This value is too high based on the Rule of Nines calculation.
B. 45% TBSA
This overestimates the burn area.
C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:
- Entire right arm (anterior + posterior): 9%
- Posterior trunk: 18%
- Posterior right leg: 9%
- Total TBSA = 9% + 18% + 9% = 36%
D. 27% TBSA
This underestimates the affected areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Continue to monitor the client as a paralytic ileus is possible
Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.
B. Administer the PRN stool softener to the client
A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.
C. Obtain an order to insert a nasogastric tube set to low suction
An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.
D. Report the assessment findings to the surgeon
Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.
Correct Answer is C
Explanation
A. Deep purple erythema
This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.
B. Facial nerve deficits
This indicates nerve injury, which is serious but may not be immediately life-threatening.
C. Dysphonia or dysphagia
Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.
D. Heart rate of 100 and blood pressure of 96/68
These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.
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