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. The law which regulated the practice of nursing profession in the Philippines is:

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. Can soluble fibers be fermented by gut bacteria?

Correct answer: A

Rationale: Soluble fibers can indeed be fermented by gut bacteria in the large intestine, leading to the production of beneficial short-chain fatty acids. This fermentation process is important for gut health and provides various health benefits. Therefore, the statement is true. Choice B is incorrect as it contradicts the known scientific fact that soluble fibers can be broken down by gut bacteria through fermentation.

4. What are sheets/forms that provide an efficient and time-saving way to record information that must be obtained repeatedly at regular and/or short intervals of time? This does not replace progress notes; instead, it records information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc. These are used whenever specific measurements or observations need to be documented repeatedly. What is this?

Correct answer: A

Rationale: The correct answer is A, Nursing Kardex. Nursing Kardex is a tool used for documenting essential patient information that needs to be recorded repeatedly at regular intervals. It includes vital signs, intake and output, treatment details, postoperative care, postpartum care, and diabetic regimen. This tool is efficient and time-saving for healthcare professionals. Choice B, Graphic Flow Sheets, may be used for visual representation of patient data but is not specifically designed for repeated documentation of essential information. Choice C, Discharge Summary, is a document outlining the patient's care and condition at the time of discharge, not for repeated recording of ongoing data. Choice D, Medicine and Treatment Record, focuses more on specific medications and treatments rather than a comprehensive recording of various patient data needed at regular intervals.

5. If the child does not have ear problem, using IMCI, what should you as the nurse do?

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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