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. Which outcome has been shown to be most closely associated with breastfeeding infants of mothers who smoke?

Correct answer: C

Rationale: The correct answer is C: vomiting. Infants breastfed by mothers who smoke are more likely to experience vomiting and gastrointestinal issues due to the transfer of nicotine and other harmful substances through breast milk. Choices A, B, and D are incorrect. Poor temperature regulation, vision impairment, and elevated blood pressure are not the primary outcomes closely associated with breastfeeding infants of mothers who smoke.

3. 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.

4. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:

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.

5. A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?

Correct answer: A

Rationale: Encouraging the client to participate in developing a system of rewards is an essential part of the plan of care for a client with anorexia nervosa. This action can help motivate and engage the client in their treatment plan, promoting a sense of achievement and progress. Choice B, arranging for someone to remain with the client for 30 minutes after meals, may not address the underlying issues related to anorexia nervosa and could potentially disrupt the client's independence. Choice C, offering a selection of beverages at each meal, is not directly related to addressing the client's condition of anorexia nervosa. Choice D, informing the client about an expected weight gain, could increase anxiety and may not be appropriate without considering the client's individual progress and readiness.

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