A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

Provide at least 5000 kcal/day.

Start an oral diet on the first day.

Administer a diet high in protein.

Collaborate with a registered dietitian.

Offer frequent high-calorie snacks.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason: Providing at least 5000 kcal/day is essential for a patient with burn injuries. Burns significantly increase the body's metabolic rate and caloric needs to support the healing process and prevent catabolism. Ensuring an adequate caloric intake helps meet the energy demands required for tissue repair and recovery.

Choice B reason: Starting an oral diet on the first day may not be appropriate for all burn patients, particularly those with extensive burns or those who are not yet stable. Nutrition needs should be carefully assessed, and feeding may begin via alternative methods such as enteral nutrition until the patient is ready for oral intake.

Choice C reason: Administering a diet high in protein is crucial for burn patients, as protein is essential for wound healing, maintaining lean body mass, and supporting the immune system. Protein intake should be increased to help repair damaged tissues and promote recovery.

Choice D reason: Collaborating with a registered dietitian is important to create an individualized nutrition plan that meets the specific needs of the burn patient. A dietitian can provide expertise in calculating caloric and protein requirements, recommending appropriate supplements, and monitoring the patient's nutritional status.

Choice E reason: Offering frequent high-calorie snacks helps ensure that the patient meets their increased caloric needs. Small, frequent meals and snacks can be more manageable for patients with reduced appetite or those who have difficulty consuming large meals. High-calorie snacks provide additional energy to support healing and recovery.

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Correct Answer is D

Explanation

Choice A reason: Completion of antibiotic therapy does not necessarily correlate with a decrease in the risk of infection in burn patients. While antibiotics can help manage existing infections, the risk for new infections remains until the burn wounds are fully healed. Open burn wounds provide a portal of entry for pathogens, and the presence of necrotic tissue can further increase infection risk.

Choice B reason: Returning albumin levels to normal can improve the overall nutritional status and healing process of a burn patient, but it does not directly reduce the risk of infection. Albumin levels are more indicative of the patient's nutritional status and fluid balance. The primary concern for infection risk remains the open burn wounds, which serve as a direct route for pathogens.

Choice C reason: Completion of the fluid resuscitation process is crucial for stabilizing a burn patient's hemodynamic status and ensuring adequate perfusion to tissues. However, fluid resuscitation does not directly impact the risk of infection. The risk of infection is predominantly related to the presence and extent of open burn wounds.

Choice D reason: The correct response is that the risk for infection significantly decreases when all of the burn wounds have closed. Closed wounds provide a barrier against pathogens and reduce the risk of infection. Wound closure can be achieved through natural healing or surgical interventions such as skin grafting. Until the wounds are fully closed, the patient remains at a high risk for infection.

A. BP 110/62, atrial fibrillation with HR 82, bilateral basilar crackles. B. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise. C. SpO2 92% on 2L nasal cannula, respirations 20/min, 1+ edema of lower extremities. D. Confusion, urine output 15 mL over the last 2 hours, orthopnea.

Correct Answer is D

Explanation

Choice A reason: While atrial fibrillation, bilateral basilar crackles, and a blood pressure of 110/62 indicate important findings in a client with heart failure, they are not immediately life-threatening compared to the symptoms in choice d. Bilateral crackles suggest fluid overload and pulmonary congestion, which require attention, but the priority should be on more critical signs of decreased perfusion.

Choice B reason: Weight gain of 1 kg in 3 days and mild dyspnea with exercise are signs of fluid retention and worsening heart failure. However, they are not as urgent as the symptoms of confusion and low urine output, which suggest severe hypoperfusion and potential organ failure.

Choice C reason: A SpO2 of 92% on 2L nasal cannula, respirations of 20/min, and 1+ edema of the lower extremities indicate mild hypoxemia and fluid overload. Although these findings are important and need management, they are not as critical as the symptoms in choice d, which suggest severe hypoperfusion and a potential emergency.

Choice D reason: Confusion, urine output of 15 mL over the last 2 hours, and orthopnea are the most concerning findings. Confusion indicates decreased cerebral perfusion, which is a sign of severe heart failure and possibly impending cardiogenic shock. Low urine output (oliguria) suggests poor renal perfusion, indicating that the kidneys are not receiving enough blood flow. Orthopnea (difficulty breathing while lying down) is a classic symptom of severe heart failure and pulmonary congestion. These symptoms suggest that the client is in a critical condition that requires immediate intervention to improve perfusion and prevent further deterioration.

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A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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