A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?

Schedule meals at 6-hr intervals.

Maintain calorie intake at 1,500 per day.

Keep a calorie count for foods and beverages.

Provide a low-protein, high-carbohydrate diet.

Answer and Explanation

The Correct Answer is C

A. Scheduling meals at 6-hour intervals is inadequate as clients with major burns require frequent, high-calorie intake.

B. A calorie intake of 1,500 per day is insufficient for burn clients, who require significantly higher caloric intake to support healing.

C. Keeping a calorie count helps ensure the client is meeting their increased nutritional needs for wound healing and recovery.

D. A high-protein, high-carbohydrate diet is necessary, not a low-protein diet, to support tissue repair and metabolic demands.

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Correct Answer is B

Explanation

A. While avoiding harsh soap is important, using water alone may not adequately clean the area.

B. After cleaning the urethral meatus, the nurse should discard the washcloth or use a different part of it to prevent the spread of bacteria.

C. Clean gloves are typically sufficient unless the procedure involves a sterile environment.

D. The penis should be cleaned from the tip to the base (proximal to distal) to reduce the risk of introducing bacteria.

A. Monitor vital signs every hour for the first 4 hr. B. Administer medications intramuscularly. C. Provide a diet low in protein. D. Observe for bruising of the skin.

Correct Answer is D

Explanation

A. Monitor vital signs every hour for the first 4 hr: Incorrect. Vital signs should be monitored more frequently, typically every 15 minutes during the first hour after administration, due to the risk of bleeding.

B. Administer medications intramuscularly: Incorrect. Intramuscular injections should be avoided while the client is on alteplase due to the increased risk of bleeding.

C. Provide a diet low in protein: Incorrect. There is no need for a low-protein diet with alteplase therapy. The focus should be on managing bleeding risks and monitoring for complications.

D. Observe for bruising of the skin: Alteplase is a thrombolytic medication, and one of its major side effects is bleeding. The nurse should monitor the client for signs of bruising, bleeding, or hemorrhage.

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A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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