HESI MEDSURG LEVEL 4 EXAM

HESI MEDSURG LEVEL 4 EXAM A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? You Selected:  36% Correct response:  36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area. Reference:  Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848 Add a Note Question 2 See full question 22s Report this Question When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? You Selected:  Ineffective airway clearance related to edema of the respiratory passages Correct response:  Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process isn't appropriate because burns aren't a disease. Disturbed sleep pattern related to facility environment and Risk for infection related to breaks in the skin may be appropriate, but they don't command a higher priority than Ineffective airway clearance because they don't reflect immediately life-threatening problems. Reference:  Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1857. Chapter 62: Management of Patients with Burn Injury - Page 1857 Add a Note Question 3 See full question 1m 17s Report this Question In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? You Selected:  A urine output consistently above 40 ml/hour Correct response:  A urine output consistently above 40 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators. Reference