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 ["B","C","D"]
Explanation
Choice A reason: The inability to retract foreskin is not typically associated with epispadias. This condition is characterized by the urethral opening being on the dorsal side of the penis.
Choice B reason: In epispadias, the urethral opening is located on the dorsal side of the penis, which is a key characteristic of this condition.
Choice C reason: A widened pubic symphysis is often seen in epispadias due to the associated pelvic bone structure abnormalities.
Choice D reason: Bladder exstrophy is commonly associated with epispadias and involves the bladder being exposed outside the abdomen.
Correct Answer is C
Explanation
Choice A reason: Digoxin is used to treat heart conditions by slowing the heart rate and increasing its efficiency. It does not increase the heart rate. The normal heart rate for a 12-month-old infant ranges from 80 to 160 beats per minute.
Choice B reason: If an infant vomits after taking digoxin, repeating the dose could lead to toxicity. Instead, caregivers should wait until the next scheduled dose or contact a healthcare provider for guidance.
Choice C reason: Administering digoxin at regular intervals ensures consistent therapeutic levels in the bloodstream, which is crucial for the medication's efficacy and safety.
Choice D reason: Offering fluids after medication does not interfere with digoxin's absorption. However, caregivers should be aware of the signs of digoxin toxicity, which include vomiting, lethargy, and bradycardia.
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