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. What physiological role does phosphorus play in the body?

Correct answer: D

Rationale: The correct answer is D. Phosphorus plays a crucial role in ATP energy release, the metabolism of fats, carbohydrates, and proteins, and regulation of acid-base balance. Choices A, B, and C are incorrect. Phosphorus is not directly involved in blood clotting, transmission of nerve impulses, muscle contraction, or calcium homeostasis. It also has known metabolic functions and is not associated with caries prevention.

3. A client is being prepared for placement of a catheter for total parenteral nutrition. Which of the following access sites should be planned for catheter insertion?

Correct answer: B

Rationale: The correct answer is the Right subclavian vein. When preparing a client for placement of a catheter for total parenteral nutrition, the preferred access site for catheter insertion is the subclavian vein due to its large size, central location, and lower risk of infection compared to peripheral veins. The other options provided (Left antecubital vein, Right femoral artery, and Left arm radial artery) are not suitable access sites for central venous catheter insertion for total parenteral nutrition.

4. What type of debridement involves proteolytic enzymes?

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

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