a nurse is planning care for a toddler who has burns over 50 total body surface area which of the following actions should the nurse include in the pl a nurse is planning care for a toddler who has burns over 50 total body surface area which of the following actions should the nurse include in the pl
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Nursing Elites

ATI RN

ATI Nutrition 2024 NGN Exam

1. A nurse is planning care for a toddler who has burns over 50% total body surface area. Which of the following actions should the nurse include in the plan of care?

Correct answer: A

Rationale: Administering enteral feedings ensures adequate nutrition and supports healing in toddlers with extensive burns.

2. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

3. A client is prescribed Ciprofloxacin and seeks guidance from a nurse. Which instruction should the nurse provide?

Correct answer: B

Rationale: The correct answer is B: 'Avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products due to the interference of calcium with medication absorption. Taking Ciprofloxacin 1 hour before or 2 hours after consuming dairy products ensures optimal effectiveness. Choice A is incorrect because Ciprofloxacin is usually taken on an empty stomach or with a light meal, not necessarily with heavy meals. Choice C is incorrect as there is no specific instruction to take Ciprofloxacin at bedtime. Choice D is incorrect because there is no need to increase potassium-rich foods intake specifically related to Ciprofloxacin use.

4. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

5. In defining a mental disorder, deviance refers to?

Correct answer: D

Rationale: In defining a mental disorder, deviance refers to behavior that is culturally unexpected or violates social norms. This means that the individual displays behaviors that are not typical or acceptable within their specific culture or society. Choices A, B, and C are incorrect because they do not directly relate to the concept of deviance in the context of defining a mental disorder. The amount of suffering, inability to fulfill a role, or capacity to cause harm are important considerations in understanding mental disorders but are not specifically related to deviance.

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