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"]
Explanation
Choice A reason: Increased urinary output is not typically associated with heart failure. In fact, reduced urinary output may be expected due to decreased kidney perfusion.
Choice B reason: Nasal flaring is a sign of respiratory distress and can be expected in infants with heart failure as they struggle to maintain oxygenation.
Choice C reason: Peripheral edema is a common finding in heart failure due to fluid retention and poor circulation.
Choice D reason: Bradycardia is not a typical sign of heart failure in infants; tachycardia is more common. However, bradycardia can occur in advanced stages due to poor cardiac output.
Choice E reason: Cool extremities are indicative of poor perfusion, which is a consequence of decreased cardiac output in heart failure.
Correct Answer is C
Explanation
Choice A reason: Collecting a stool specimen for culture is not the preferred method for diagnosing Enterobius vermicularis, as the pinworm eggs are rarely present in the stool.
Choice B reason: Initiating IV fluids is not a diagnostic measure for Enterobius vermicularis and is not relevant unless the child is dehydrated or requires fluids for another reason.
Choice C reason: The tape test is the standard diagnostic procedure for Enterobius vermicularis. It involves placing clear tape around the anus to collect any eggs that may be present, which are then examined under a microscope.
Choice D reason: Testing the stool for occult blood is not a diagnostic measure for Enterobius vermicularis, as this infection does not typically cause bleeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.