during the first 24 hours after the thermal injury you should asses sergio for
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Nursing Elites

ATI RN

Nutrition ATI Test

1. During the first 24 hours after the thermal injury, you should assess Sergio for:

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

2. What is the term for a barrier that prevents the normal emptying of stomach contents into the duodenum?

Correct answer: C

Rationale: Gastric outlet obstruction refers to a condition where the opening between the stomach and the duodenum is blocked, preventing the normal passage of food. This is why choice 'C' is correct. 'A: Dumping syndrome' is incorrect because it is a condition where stomach contents move too quickly through the small intestine, not a barrier preventing emptying. 'B: Gastritis' is inflammation of the stomach lining, not a blockage of the outlet. 'D: Hypochlorhydria' refers to low stomach acid, which may affect digestion but does not create a physical barrier blocking the outlet of the stomach.

3. What does a sample group represent?

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. Mr. Bradley has been advised to limit his dairy product intake. What principle regarding fluid intake should be followed?

Correct answer: A

Rationale: For patients with kidney disease, it's important to manage fluid intake from all sources, including foods like gelatin and soups, which can contribute to fluid overload.

5. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

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