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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Preschool-age children are beginning to understand causality, but they do not fully grasp the cause of illnesses, which often involves complex biological processes.
Choice B reason: While preschoolers are becoming more aware of their bodies, they typically do not have a detailed understanding of body functioning.
Choice C reason: Preschoolers may describe how they feel when they are ill, but they usually cannot accurately describe the manifestations of illnesses.
Choice D reason: Preschoolers often engage in magical thinking, where they believe their thoughts can cause events. This is a normal part of their cognitive development and can include relating fears to magical thinking.
Correct Answer is C
Explanation
Choice A reason: Medication should not be cool as it can cause discomfort or even reflexive actions like vomiting or vertigo. It should be at room temperature⁷.
Choice B reason: Hyperextending the infant's neck is not necessary and could be uncomfortable or unsafe. The position should be natural and comfortable⁷.
Choice C reason: Pulling the pinna downward and straight back is the correct method for infants to straighten the ear canal for proper administration of otic medication⁷.
Choice D reason: Holding the infant in an upright position is not ideal for otic medication administration. The infant should be lying down or sitting with the affected ear facing up⁷.
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