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. Can a person with Celiac disease eat Poptarts that contain gluten?

Correct answer: B

Rationale: A person with Celiac disease cannot consume Poptarts that contain gluten because gluten is a protein found in wheat, barley, and rye, triggering an autoimmune response in individuals with Celiac disease and damaging their small intestine. Even small quantities of gluten can lead to this harmful response, making choices 'A' and 'C' incorrect. While gluten-free Poptarts may be suitable for individuals with Celiac disease, regular Poptarts containing gluten are not safe for consumption by them, rendering choice 'D' incorrect as well.

3. A client reports having difficulty losing weight. Which of the following responses by the nurse is appropriate?

Correct answer: C

Rationale: The correct answer is C: 'It is helpful to self-monitor your eating.' Self-monitoring dietary intake is an evidence-based strategy that enhances awareness and accountability, making it an effective approach for weight management. Choice A is incorrect as focusing on high-calorie foods first may not be the most effective strategy for weight loss. Choice B is too general and lacks actionable advice. Choice D, tasting food while cooking, does not directly address the client's difficulty in losing weight and is not a proven method for weight management.

4. What is the primary function of a written nursing care plan?

Correct answer: D

Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.

5. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:

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.

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