based on the nursing diagnosis of potential for infection related to second and third degree burns which intervention has the highest priority
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Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

1. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?

Correct answer: B

Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.

2. The client has chronic renal failure. What dietary modification is most important for this client?

Correct answer: B

Rationale: Limiting potassium-rich foods is crucial in chronic renal failure to prevent hyperkalemia, which can lead to cardiac complications. Excessive protein intake can increase the workload on the kidneys and may result in the accumulation of uremic toxins. Increasing sodium intake is generally discouraged in chronic renal failure due to its association with hypertension and fluid retention. Encouraging dairy products may not be suitable for all clients with chronic renal failure, as they are a significant source of phosphorus, which needs to be limited in renal failure to prevent mineral imbalances.

3. The nurse is monitoring a client who started taking a new medication for rheumatoid arthritis. What is the most important aspect to monitor?

Correct answer: D

Rationale: When a client starts a new medication for rheumatoid arthritis, it is crucial to monitor all necessary aspects based on the specific medication prescribed. Different medications can have varying side effects and impacts on different organ systems. Monitoring all relevant parameters ensures the early detection of any adverse effects and helps to maintain the client's safety. While monitoring for signs of gastrointestinal bleeding, liver function tests, and renal function tests are all important in certain situations, the priority is to conduct comprehensive monitoring based on the medication's known effects.

4. The nurse is preparing to administer an intramuscular injection to a 6-month-old infant. Which site is most appropriate for this injection?

Correct answer: D

Rationale: The vastus lateralis muscle is the preferred site for intramuscular injections in infants due to its size and safety. The deltoid muscle is typically used for adults and older children. The ventrogluteal muscle is more commonly used in toddlers and older children. The dorsogluteal muscle is not recommended for intramuscular injections in any age group due to its proximity to major nerves and blood vessels, which poses a risk of injury or sciatic nerve damage.

5. The nurse is assessing a client who has been receiving total parenteral nutrition (TPN) for several days. Which complication should the nurse monitor for?

Correct answer: B

Rationale: The correct answer is B: Hypoglycemia. When a client is receiving total parenteral nutrition (TPN) with a high glucose content, the risk of hypoglycemia is significant due to sudden increases in insulin release in response to the glucose load. The nurse should monitor for signs and symptoms of hypoglycemia such as shakiness, sweating, palpitations, and confusion. Hyperglycemia (choice A) is not typically a complication of TPN as the high glucose content is more likely to cause hypoglycemia. Hyponatremia (choice C) and hypokalemia (choice D) are electrolyte imbalances that can occur in clients receiving TPN, but hypoglycemia is the more common and immediate concern that the nurse should monitor for.

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