during the first 24 hours after the thermal injury you should asses sergio for
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Nursing Elites

ATI RN

Nutrition ATI Test

1. During the first 24 hours after the thermal injury, you should assess Sergio for:

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

2. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

3. During the first 24 hours of burn, nursing measures should focus on which of the following?

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.

4. A healthcare professional is teaching about implementing a heart-healthy diet to a client who has coronary artery disease. Which of the following foods should the professional recommend to the client?

Correct answer: C

Rationale: Broiled salmon is a heart-healthy food due to its high omega-3 fatty acid content, which helps reduce inflammation and improve cardiovascular health. Choices A, B, and D are not recommended for a heart-healthy diet. Baked ham and processed cheese are high in saturated fats and sodium, which can be detrimental to cardiovascular health. Canned potato soup may contain high levels of sodium and preservatives, making it less suitable for a heart-healthy diet.

5. The working phase in a therapy group is usually characterized by which of the following?

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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