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 D
Explanation
Choice A: This is incorrect. The client having difficulty reading large print indicates a need for an ophthalmology referral, not an occupational therapy referral. An ophthalmologist can assess and treat vision problems caused by stroke.
Choice B: This is incorrect. The client coughing while drinking from a straw indicates a need for a speech therapy referral, not an occupational therapy referral. A speech therapist can assess and treat swallowing problems caused by stroke.
Choice C: This is incorrect. The client being unable to bear her full weight while walking indicates a need for a physical therapy referral, not an occupational therapy referral. A physical therapist can assess and treat mobility problems caused by stroke.
Choice D: This is correct. The client becoming exhausted after performing activities of daily living indicates a need for an occupational therapy referral. An occupational therapist can assess and treat functional problems caused by stroke, such as fatigue, self-care, cognition, and leisure activities.
Correct Answer is B
Explanation
Choice A: This is incorrect. Potassium 4.0 mEq/L is a normal value and does not indicate heart failure.
Choice B: This is correct. Brain natriuretic peptide (BNP) is a hormone that is released by the heart when it is stretched or overloaded. A high level of BNP indicates that the heart is working harder than normal and may have heart failure. A normal BNP level is less than 100 pg/mL, so 275 pg/mL is elevated and suggestive of heart failure.
Choice C: This is incorrect. Sodium 140 mEq/L is a normal value and does not indicate heart failure.
Choice D: This is incorrect. Calcium 9.0 mg/dL is a normal value and does not indicate heart failure.
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