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. Bacterial growth and plaque formation are enhanced by a diet with frequent intake of retentive carbohydrates. Gingivitis is an irreversible change in the interdental papillary tissues.

Correct answer: C

Rationale: The correct answer is C. The first statement is true; retentive carbohydrates promote bacterial growth and plaque formation. However, the second statement is false; gingivitis is not irreversible and is often reversible with proper care. Gingivitis is the inflammation of the gums due to plaque buildup and poor oral hygiene. With good oral hygiene practices and professional dental care, gingivitis can be reversed. The other choices are incorrect because gingivitis is not irreversible, making statement two false.

3. Which vitamin is also known as Niacin?

Correct answer: C

Rationale: The correct answer is Vitamin B3, also known as Niacin. Niacin is essential for energy metabolism and can help improve cholesterol levels. Vitamin B1 is Thiamine, Vitamin B2 is Riboflavin, and Vitamin B12 is Cobalamin. These vitamins have different functions in the body and are not synonymous with Niacin.

4. Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?

Correct answer: C

Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.

5. The component that should receive the highest priority before physical examination is the:

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.

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