the nurse knows that the most fatal electrolyte imbalance in burned client during the emergent phase of burn is
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Nursing Elites

ATI RN

Nutrition ATI Test

1. During the Emergent phase of a burn, the most fatal electrolyte imbalance in a burned client is:

Correct answer: A

Rationale: During the Emergent phase of burns, the most fatal electrolyte imbalance is Hypokalemia. This is due to the shift of potassium from the intracellular space to the extracellular space, leading to low potassium levels in the blood. Choices B, C, and D are incorrect because Hyperkalemia, Hypernatremia, and Hyponatremia are not typically associated with the Emergent phase of burns and do not pose the same level of risk as Hypokalemia in this context.

2. During the phallic stage, with which parent must the child identify?

Correct answer: A

Rationale: According to Freud's psychosexual development theory, during the phallic stage (approximately ages 3 to 6), the child starts to identify with the parent of the same sex. This identification is a crucial part of the child's development and is believed to influence their adult behavior. The process involves the child adopting the characteristics, attitudes, and values of the same-sex parent. Choice B, C, and D are incorrect as they do not align with Freud's theory of the phallic stage of psychosexual development.

3. Where is Vitamin E commonly found?

Correct answer: D

Rationale: Vitamin E is an antioxidant commonly found in sources like vegetable oils, nuts, seeds, and green leafy vegetables. It plays a crucial role in protecting cells from damage. Choices A and B are incorrect as Vitamin E is not produced by bacteria in the GI tract nor synthesized by sunlight exposure. Choice C is incorrect as beriberi is a deficiency of Vitamin B1 (thiamine), not Vitamin E.

4. To ensure client safety before starting blood transfusions, the following are needed before the procedure can be done EXCEPT:

Correct answer: D

Rationale: To ensure client safety before starting blood transfusions, taking baseline vital signs, warming the blood to room temperature, and having two nurses verify client identification, blood type, unit number, and expiration date of blood are crucial steps. Consent for blood transfusion is required but is typically obtained before the procedure. The focus before the procedure should be on confirming the right client, blood product, and ensuring the blood is prepared correctly to minimize risks of transfusion reactions.

5. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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