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
The correct answer is a. "Children play alongside each other but do not interact."
Choice A reason: Parallel play is characterized by children playing next to each other without engaging in direct interaction or cooperative play, which is typical behavior at certain developmental stages.
Choice B reason: Organized play involves interaction and cooperation, which is not characteristic of parallel play.
Choice C reason: While children may play independently in a group, this statement does not capture the essence of parallel play, which involves proximity without interaction.
Choice D reason: Observing others play is more indicative of onlooker behavior rather than parallel play.
Correct Answer is C
Explanation
Choice A reason: Hyperactivity is not typically associated with chronic renal failure in children. Instead, children may experience fatigue and lethargy due to anemia and the overall decreased function of the kidneys.
Choice B reason: Weight gain can occur in chronic renal failure due to fluid retention; however, it is not as characteristic as delayed growth, which is a direct result of the disease's impact on the child's development.
Choice C reason: Delayed growth is a common finding in children with chronic renal failure due to various factors, including metabolic imbalances, bone disorders, and malnutrition, all of which can impede normal growth.
Choice D reason: A flushed face is not a typical finding in chronic renal failure. More common are signs related to fluid overload, such as swelling around the eyes, feet, and ankles, and symptoms of uremia like pallor.
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