during the first 24 hours of burn nursing measures should focus on which of the following
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Nursing Elites

ATI RN

Nutrition ATI Proctored Exam 2023

1. During the first 24 hours of burn, nursing measures should focus on which of the following?

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.

2. Which food would benefit an anemic patient by increasing their intake?

Correct answer: A

Rationale: An anemic patient would benefit from increasing their intake of beef. Beef is an excellent source of heme iron, which is critical for treating anemia. Heme iron is absorbed more readily by the body compared to non-heme iron found in plant-based foods. Apples and white bread, while healthy, do not contain significant amounts of heme iron. Fish, although it does contain iron, it's non-heme iron, which is not as efficiently absorbed by the body as heme iron, hence less effective in treating anemia.

3. A caregiver is teaching a parent about recommended protein intake for a toddler. Which of the following food selections is equivalent to 1 oz of protein?

Correct answer: D

Rationale: One scrambled egg is equivalent to 1 oz of protein, making it a suitable choice for a toddler's diet. A ½ cup of peas (choice B) does not provide 1 oz of protein but is still a good source of protein. 2 tbsp of peanut butter (choice A) contains more than 1 oz of protein. 1 slice of bread (choice C) typically provides less protein than 1 oz.

4. The mechanism behind most CKD in patients without diabetes is mediated by:

Correct answer: B

Rationale: In non-diabetic patients, CKD is often mediated by immune system responses. Chronic inflammation triggered by immune system dysfunction can contribute to progressive kidney damage. Therefore, the correct answer is 'immune systems.' Choices A, C, and D are incorrect because CKD in non-diabetic patients is primarily associated with immune system abnormalities rather than enzyme, catabolic, or hormonal systems.

5. Which of the following actions would be of highest priority with regards to the external shunt?

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

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