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. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

3. What does oliguria lead to in patients with acute kidney injury?

Correct answer: C

Rationale: In patients with acute kidney injury, oliguria (reduced urine output) often results in sodium retention and hyperkalemia (elevated levels of potassium). This is due to the kidneys' decreased capacity to excrete these substances. Choice A is incorrect because hypophosphatemia and overgrowth of bone tissue are not direct consequences of oliguria in acute kidney injury. Choice B is incorrect because an increase in blood potassium levels is not caused by excessive excretion of parathyroid hormone but rather by decreased excretion of potassium. Choice D is incorrect because edema is not caused by increased urine production but rather by fluid overload due to decreased urine output.

4. Where in the body are microvilli located, facilitating the absorption of most nutrients?

Correct answer: D: Small Intestine

Rationale: The correct answer is D: Small Intestine. Microvilli are present in the small intestine, significantly increasing its surface area for efficient absorption of nutrients. The small intestine is the primary site for nutrient absorption in the body. The stomach (choice A) primarily functions to break down food with its acidic environment but is not where most nutrients are absorbed. The pancreas (choice B) produces enzymes to aid in digestion but does not directly absorb nutrients. The large intestine (choice C) mainly absorbs water and electrolytes from undigested food, rather than nutrients.

5. A healthcare professional is preparing a list of resources in a community where nutritional status is significantly influenced by economics. What should the professional recommend?

Correct answer: D

Rationale: The correct answer is D, the Supplemental Nutrition Assistance Program (SNAP). SNAP provides financial assistance to help low-income individuals purchase food, directly addressing economic barriers to nutrition. Choices A, B, and C do not directly address the economic aspect of the community's nutritional status. A public service announcement on healthy eating may raise awareness but does not provide financial assistance. Educational programs on food safety focus on a different aspect of nutrition. The MyPyramid food guidance system is a tool for healthy eating but does not address the economic challenges faced by the community.

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