A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes absent bowel sounds in all quadrants. To maintain adequate nutrition, which action should the nurse plan to take?
Administer multiple vitamins and minerals in the IV solution.
Infuse total parenteral nutrition via a central catheter.
Insert a feeding tube and initiate enteral feedings.
Encourage an oral intake of at least 3000 kcal per day.
The Correct Answer is B
Choice A reason: While administering vitamins and minerals is important, it does not provide complete nutrition, especially for a client with such extensive burns and absent bowel sounds.
Choice B reason: This is the correct choice because total parenteral nutrition (TPN) provides complete nutrition intravenously, bypassing the gastrointestinal tract, which is necessary when bowel sounds are absent, indicating a non-functioning GI system.
Choice C reason: Enteral feedings require a functioning GI tract. With absent bowel sounds, this indicates a high risk for complications like aspiration or feeding intolerance.
Choice D reason: Encouraging oral intake is not feasible for a client with extensive burns and absent bowel sounds due to the high risk of inadequate intake and aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A blood creatinine level of 1.3 mg/dL is elevated for a school-age child and indicates impaired kidney function, which is a concern in acute glomerulonephritis.
Choice B reason: A urine output of 550 mL in 24 hours is within the normal range for a school-age child and does not need to be reported unless there is a significant change.
Choice C reason: A blood pressure of 100/74 mm Hg is within the normal range for a school-age child and does not indicate an immediate concern.
Choice D reason: A BUN level of 8 mg/dL is within the normal range for a school-age child and does not need to be reported unless there is a significant change.
Correct Answer is B
Explanation
Choice A reason: Positioning a child supine after a tonsillectomy is not recommended due to the risk of respiratory complications. Elevating the head of the bed is preferred to prevent aspiration and facilitate breathing.
Choice B reason: Administering analgesics on a schedule is crucial for effective pain management. It helps maintain consistent pain relief, which is important for encouraging fluid intake and preventing dehydration.
Choice C reason: Encouraging a child to blow their nose gently after a tonsillectomy is not advised because it can increase the risk of bleeding. Instead, gentle mouth breathing and avoiding nose blowing are recommended.
Choice D reason: Offering orange juice after a tonsillectomy is not ideal as acidic beverages can irritate the throat. It's better to provide non-acidic fluids like water or apple juice to keep the child hydrated.
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