during the acute phase of burn the priority nursing intervention in caring for this client is
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Nursing Elites

ATI RN

ATI RN Nutrition Online Practice 2019

1. During the acute phase of a burn, the priority nursing intervention in caring for this client is:

Correct answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.

2. After cleaning the abrasions and applying antiseptic, the nurse applies a cold compress to the swollen ankle as ordered by the physician. This statement shows that the nurse has a correct understanding of the use of a cold compress:

Correct answer: C

Rationale: The correct understanding of using a cold compress includes knowing that it helps prevent edema and reduces pain. Cold application constricts blood vessels, reducing blood flow to the area, which helps decrease swelling and pain. Choices A, B, and D are incorrect because cold compresses do not directly affect blood viscosity, safety compared to hot compresses, or eliminate toxic waste products due to vasodilation. It is essential for nurses to have a clear understanding of the rationale behind interventions to provide effective patient care.

3. The most common causative agent of Pyelonephritis in hospitalized patient attributed to prolonged catheterization is said to be:

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. Digestible carbs are absorbed as ___ through the small intestinal wall and are delivered to the liver, which releases ___ into the bloodstream.

Correct answer: B

Rationale: Digestible carbohydrates are absorbed as monosaccharides (simple sugars) like glucose, which the liver can release into the bloodstream for energy.

5. Dietary fiber has been recommended for its possible benefits in reducing heart disease by lowering blood cholesterol. How is fiber thought to play its role in lowering blood cholesterol?

Correct answer: B

Rationale: The correct answer is B. Viscous (soluble) fiber binds with bile acids in the intestine, which are then excreted. The liver must use cholesterol to make more bile acids, thereby lowering blood cholesterol levels. Choice A is incorrect as insoluble fiber does not bind with cholesterol in the large intestine. Choice C is incorrect as soluble fiber does not directly bind with cholesterol in the blood. Choice D is incorrect as insoluble fiber does not convert to bile in the large intestine to bind with cholesterol.

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