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. Sugar alcohols have anticariogenic properties and can protect the teeth by decreasing demineralization, enhancing remineralization, or increasing salivary flow, even in the presence of a fermentable carbohydrate. Name 3 sugar alcohols.

Correct answer: D

Rationale: Sugar alcohols such as sorbitol, mannitol, and xylitol are commonly used in sugar-free products and have properties that help protect teeth from caries by promoting remineralization and increasing salivary flow. Erythritol is another common sugar alcohol used as a sweetener in various products, but it was not listed in the question.

3. In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within:

Correct answer: B

Rationale: In an extreme situation where no other resident or intern is available, if a nurse receives telephone orders, the order has to be correctly written and signed by the physician within 36 hours. This time frame ensures timely documentation and validation of the orders. Choice A (24 hours) is too short a period for busy physicians to fulfill the task. Choice C (48 hours) is too long and delays the incorporation of physician orders into the patient's care plan. Choice D (12 hours) may not provide enough time for the physician to review and sign the order, especially in situations where immediate attention is not required.

4. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. What instruction should the nurse include on weight gain during pregnancy?

Correct answer: A

Rationale: Appropriate weight gain is crucial for reducing the risk of preterm birth.

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