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. A nurse is caring for a client who is receiving parenteral nutrition. Which of the following findings indicates the therapy is effective?

Correct answer: D

Rationale: The correct answer is D because having a blood glucose level within the expected reference range indicates that parenteral nutrition is effectively meeting the client's nutritional needs. Choices A, B, and C are incorrect because soft, formed bowel movements, pink mucous membranes, and the ability to complete activities of daily living do not directly reflect the effectiveness of parenteral nutrition therapy.

3. In a therapeutic relationship, the nurse must understand own values, beliefs, feelings, prejudices & how these affect others. This is called:

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. Each statement is true of rickets, except one. Which is the exception?

Correct answer: B

Rationale: Rickets is caused by vitamin D deficiency, not vitamin C deficiency. It usually occurs in children who are 1 to 3 years old. The name rickets came from the word 'wrikken,' meaning 'to bend or twist.' Common manifestations of rickets include tachetic deformities like bow legs or knock-knees, a narrow and distorted chest, and failure of the epiphyses of bones to develop normally, resulting in twisted and warped bones. While the diagnosis of rickets may be increasing in the United States, it is not caused by a lack of vitamin C.

5. You would expect that after an abdominal perineal resection, the type of colostomy that will be use is?

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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