A nurse is providing care to a client who has sustained deep partial-thickness burns to the back of both legs. Which of the following actions should the nurse anticipate taking?
Restrict the client's calorie intake to no more than 2,000 calories per day.
Change sterile gloves between caring for wounds on different areas of the body.
Limit movement or bending of the client's affected extremities.
Administer a diuretic if the client's urine output falls below 30 mL/hr.
The Correct Answer is B
Choice A reason: Restricting the client's calorie intake to no more than 2,000 calories per day is not an appropriate action, as it can impair wound healing and increase the risk of infection or malnutrition. The nurse should provide adequate calories and protein to meet the increased metabolic demands and support tissue repair and regeneration.
Choice B reason: Changing sterile gloves between caring for wounds on different areas of the body is an appropriate action, as it can prevent cross-contamination and infection of the burn wounds, which are susceptible to bacterial colonization and sepsis.
Choice C reason: Limiting movement or bending of the client's affected extremities is not an appropriate action, as it can cause contractures, joint stiffness, or muscle atrophy in the burned areas. The nurse should encourage early and frequent range of motion exercises and use splints or positioning devices to maintain functional alignment and mobility.
Choice D reason: Administering a diuretic if the client's urine output falls below 30 mL/hr is not an appropriate action, as it can worsen dehydration, electrolyte imbalance, or renal failure that can occur after severe burns. The nurse should monitor fluid status and urine output closely and administer intravenous fluids as prescribed to maintain adequate hydration and perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying restraints to the client is not an appropriate action, as it can cause injury or suffocation to the client during a seizure. The nurse should protect the client from harm by removing any nearby objects and padding the side rails.
Choice B reason: Administering an IV bolus of lorazepam is an appropriate action, as lorazepam is an anticonvulsant drug that can stop or shorten the duration of a seizure by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain.
Choice C reason: Placing the client in the prone position is not an appropriate action, as it can obstruct the airway and cause respiratory distress or aspiration during a seizure. The nurse should place the client in the side-lying position to facilitate drainage of oral secretions and prevent tongue biting.
Choice D reason: Inserting a tongue blade into the client's mouth is not an appropriate action, as it can cause oral trauma or choking during a seizure. The nurse should never force anything into the client's mouth during a seizure and should allow them to breathe spontaneously.
Correct Answer is B
Explanation
Choice A Reason:
The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.
Choice B Reason:
The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.
Choice C Reason:
The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.
Choice D Reason:
The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.
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