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Question 1 of 5

A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:

Correct Answer: B

Rationale: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%; assuming only the anterior trunk is affected (18%), the total TBSA is 27%, but 35% is the closest reasonable estimate for partial and full-thickness burns.

Question 2 of 5

When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?

Correct Answer: D

Rationale: Dietary intake, particularly of phosphorus-rich foods, is the most significant factor in assessing hyperphosphatemia risk, as excessive intake can elevate serum phosphate levels.

Question 3 of 5

During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:

Correct Answer: A

Rationale: Writing unverified suspicions of illegal drug use that are later seen by others constitutes libel, as it is a written defamatory statement.

Question 4 of 5

After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?

Correct Answer: C

Rationale: Triage prioritizes life-threatening conditions. The 25-year-old with minor injuries (abrasion, swollen ankle) is the least urgent compared to potential cardiac, neurological, or traumatic injuries.

Question 5 of 5

All of the following clients are at an increased risk for aspiration pneumonia EXCEPT

Correct Answer: B

Rationale: Aspiration pneumonia risk is high with nasogastric feeding, mechanical ventilation, and dysphagia due to potential airway entry of material.
Total parenteral nutrition (IV) bypasses the airway, reducing aspiration risk.

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