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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

Answer and Explanation

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.

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Correct Answer is ["C","E","F"]

Explanation

A. The correct rate is 6 mL/hr

The correct calculation should be verified.

B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K

Protamine sulfate, not vitamin K, is the antidote for heparin.

C. The nurses will complete an event report due to the medication error

A medication error must be reported.

D. Nurse A will document about the event report in the patient’s EMR

Incident reports are internal documents and should not be documented in the EMR.

E. The patient has received a dose of heparin over the prescribed amount

Due to the increased concentration, the patient received more heparin than intended.

F. The patient has received 3200 units of heparin from 1700-1900.

This calculation confirms overdosing.

A. Respiratory rate 24 and bloody drainage in the NG tube B. Client is oriented to name and place but not the date C. Blood pressure 4/48 and urine output of 24 mL/hour D. Hypo-active bowel sounds and tachycardia

Correct Answer is C

Explanation

A. Respiratory rate 24 and bloody drainage in the NG tube

While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.

B. Client is oriented to name and place but not the date

This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.

C. Blood pressure 40/48 and urine output of 24 mL/hour

This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.

D. Hypo-active bowel sounds and tachycardia

Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E","F"]

Explanation

Correct Answer is C

Explanation

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Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

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