A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?
Place the client on a low-carbohydrate diet.
Monitor the client's calorie intake daily.
Place the client on strict bed rest.
Weigh the client once per week.
The Correct Answer is B
A) Place the client on a low-carbohydrate diet:
A low-carbohydrate diet is not appropriate for a client with full-thickness burns, as their nutritional needs are significantly increased due to the high metabolic demands of wound healing. A high-calorie, high-protein diet is usually recommended to support recovery and manage the increased energy expenditure associated with burn injuries.
B) Monitor the client's calorie intake daily:
Daily monitoring of calorie intake is crucial for clients with significant burn injuries. Burns increase metabolic demands, and the client’s nutritional needs must be closely tracked to ensure adequate caloric and protein intake, which is essential for wound healing and overall recovery. Regular monitoring helps adjust dietary needs as required.
C) Place the client on strict bed rest:
Strict bed rest is not indicated for clients with burns, as mobility and physical therapy are important for maintaining muscle strength and preventing complications like contractures. While rest is important, a balanced approach involving gradual mobilization is preferred to support functional recovery.
D) Weigh the client once per week:
Weekly weighing may not be frequent enough for clients with burn injuries, as their weight can fluctuate significantly due to changes in fluid status and nutritional needs. More frequent monitoring is necessary to ensure that the client is receiving adequate nutrition and to assess their overall progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "The spacer should make a whistling sound as you inhale":
The spacer should not make a whistling sound; this often indicates that the client is inhaling too quickly. The goal is to inhale slowly and deeply to ensure the medication is delivered effectively to the lungs.
B) "Wait 30 seconds between puffs":
Waiting 30 seconds between puffs is typically not necessary for most inhaled medications. The general recommendation is to wait about 1 minute if using the same medication and up to 5 minutes if using different medications, but this varies depending on the specific inhaler and medication.
C) "Hold your breath for 10 seconds once you inhale":
Holding the breath for 10 seconds after inhaling is important for ensuring that the medication reaches deep into the lungs and is not prematurely exhaled. This practice helps maximize the effectiveness of the medication.
D) "Clean the spacer daily with cold water":
Spacers should be cleaned regularly, but not necessarily daily. They should be cleaned at least once a week, and warm soapy water is usually recommended. Cold water may not effectively remove all residues or bacteria.
Correct Answer is D
Explanation
A) A client who has a headache following a grade 1 concussion:
A headache following a grade 1 concussion usually indicates a mild injury. Although the client may need monitoring, they are not typically at high risk for rapid deterioration that would necessitate proximity to the nurses' station.
B) A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack:
A score of 0 on the NIH Stroke Scale indicates no symptoms of stroke. While close monitoring is important after a transient ischemic attack, this client’s condition is stable, and they might not need to be in the room closest to the nurses' station.
C) A client who has experienced brain death and is awaiting organ procurement:
A client who has experienced brain death is typically stable in terms of neurological status, although they may require monitoring for other reasons. However, their neurological condition would not require immediate proximity to the nurses' station compared to more acute conditions.
D) A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash:
A score of 10 on the Glasgow Coma Scale indicates moderate to severe impairment of consciousness, which suggests a higher risk of rapid deterioration. This client should be placed in the room closest to the nurses' station for continuous monitoring and immediate intervention if needed.
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