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. Why are blood glucose levels high in type 1 diabetes?

Correct answer: D

Rationale: In type 1 diabetes, the body's immune system destroys the beta cells in the pancreas that produce insulin. This leads to an insufficient amount of insulin, which is required to facilitate the transport of glucose into the cells. Consequently, blood glucose levels remain high. The other options are incorrect. Option A is incorrect because urinary excretion of glucose does not directly contribute to blood glucose levels. Option B is incorrect because, while gluconeogenesis does produce glucose, it is not the cause of high glucose levels in type 1 diabetes. Option C is incorrect because absorption efficiency of glucose from the gastrointestinal tract does not affect the amount of insulin available to transport glucose into cells.

3. A paranoid client refuses to eat telling you that you poisoned his food. The best intervention to this client is:

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. A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following foods is a good source of high-quality protein?

Correct answer: A

Rationale: Soybeans are a good source of high-quality protein. They contain all the essential amino acids needed by the body. Grains, legumes, and green vegetables do not provide as much high-quality protein as soybeans. Grains and legumes are good sources of protein but may lack some essential amino acids, while green vegetables generally have lower protein content compared to soybeans.

5. A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements should the nurse make?

Correct answer: D

Rationale: During chemotherapy treatments for chronic lymphocytic leukemia, raw fruits and vegetables are recommended as they are easier for the body to digest. This choice provides essential nutrients and is gentle on the digestive system. Option A is incorrect because staying hydrated is crucial during chemotherapy. Option B is incorrect as low-calorie foods may not provide sufficient energy during treatment. Option C is incorrect because high-fat foods are not typically recommended due to potential digestive issues.

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