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 food has the highest calcium content?

Correct answer: B

Rationale: The correct answer is B, milk. Milk is known for being one of the best dietary sources of calcium, essential for bone health and various bodily functions. Soy products, cereal grains, and dark green vegetables are good sources of calcium as well, but milk generally has a higher calcium content compared to these options.

3. What is the most likely demonstration of cardiac cachexia?

Correct answer: B

Rationale: Cardiac cachexia is a condition characterized by severe weight loss and tissue wasting. This typically occurs in patients suffering from heart failure due to an increased energy expenditure and reduced appetite, which is why choice B is the correct answer. The other choices are incorrect as they do not accurately describe the symptoms of cardiac cachexia. Decreased physical activity (choice A) can be a result of many conditions, not specifically cardiac cachexia. Poor urine output and tissue edema (choice C) are more indicative of kidney problems rather than cardiac cachexia. Finally, cardiac arrhythmia and wet lung sounds (choice D) are symptoms related to other cardiac conditions, not specifically to cardiac cachexia.

4. Being in contact with reality and the environment is a function of the:

Correct answer: B

Rationale: Being in contact with reality and the environment is a function of the ego. The ego is responsible for mediating between the id's basic desires, the superego's idealistic standards, and the real world. The conscience (not listed as a choice) is related to feelings of guilt or moral responsibility. The id represents primal instincts, and the superego represents the internalized ideals and moral standards.

5. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps, sphygmomanometer, and similar devices/machines. As a staff member, how can you improve the safety of using infusion pumps?

Correct answer: D

Rationale: To enhance the safety of using infusion pumps, it is crucial to verify the flow rate against your calculation. This step ensures that the prescribed dosage is being delivered accurately, reducing the risk of medication errors. Checking the functionality of the pump before use (Choice A) is also important to ensure it is working properly. Allowing the technician to set the pump (Choice C) may not always guarantee the correct settings. Selecting the brand of infusion pump carefully (Choice B) is not directly related to the safe use of the pump.

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