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. During the first 24 hours after the thermal injury, you should assess Sergio for:

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

3. What is the term for the act of performing beneficial services rather than harmful ones?

Correct answer: A

Rationale: The term for the act of performing beneficial services rather than harmful ones is 'Beneficence'. Beneficence refers to actions that enhance the well-being of others. In the healthcare context, beneficence ensures that health services are advantageous and beneficial to patients. 'Disclosure' (choice B) is the act of revealing information, not directly related to whether actions are beneficial or harmful. 'Maleficence' (choice C) is the opposite of beneficence, involving actions that can cause damage or harm. 'Justice' (choice D) denotes fairness and equality, important in various contexts but not specifically related to performing beneficial services.

4. Which nutrient deficiency produces microcytic anemia, fatigue, faulty digestion, blue sclerae, pale conjunctivae, and tachycardia?

Correct answer: B

Rationale: A deficiency in iron can lead to various symptoms, such as microcytic anemia, fatigue, faulty digestion, blue sclerae, pale conjunctivae, and tachycardia. Iron-deficiency anemia may be caused by inadequate dietary intake; accelerated demand or losses; and inadequate absorption secondary to diarrhea, decreased acid secretions, or antacid therapy. Iron deficiency is frequently the result of postnatal feeding practices and has a serious impact on growth and mental and psychomotor development in infants and children. Choices A, C, and D are incorrect as zinc deficiency typically presents with symptoms like impaired wound healing, taste abnormalities, and hair loss; sodium deficiency can lead to symptoms such as muscle cramps, dizziness, and confusion; and potassium deficiency may cause muscle weakness, fatigue, and abnormal heart rhythms.

5. The most energy-rich nutrient is:

Correct answer: B

Rationale: Fat provides 9 kcal per gram, making it the most energy-rich nutrient compared to carbohydrates and proteins, which provide 4 kcal per gram.

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