A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?

Decreased calcium levels.

Increased serum glucose levels.

Absent bowel sounds.

Intermittent abdominal pain.

Answer and Explanation

The Correct Answer is B

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Correct Answer is C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

A. Have an assistive personnel feed the client. B. Apply foam handles to the client's eating utensils. C. Obtain a referral for physical therapy. D. Ask the provider for a prescription for a pureed diet.

Correct Answer is B

Explanation

Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.

Reasons why the other options are not answers:

Option A: Having an assistive personnel feed the client may decrease the client's autonomy.

Option C: Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.

Option D: Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.

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A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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