A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes absent bowel sounds in all quadrants. To maintain adequate nutrition, which action should the nurse plan to take?
Administer multiple vitamins and minerals in the IV solution.
Infuse total parenteral nutrition via a central catheter.
Insert a feeding tube and initiate enteral feedings.
Encourage an oral intake of at least 3000 kcal per day.
The Correct Answer is B
Choice A reason: While administering vitamins and minerals is important, it does not provide complete nutrition, especially for a client with such extensive burns and absent bowel sounds.
Choice B reason: This is the correct choice because total parenteral nutrition (TPN) provides complete nutrition intravenously, bypassing the gastrointestinal tract, which is necessary when bowel sounds are absent, indicating a non-functioning GI system.
Choice C reason: Enteral feedings require a functioning GI tract. With absent bowel sounds, this indicates a high risk for complications like aspiration or feeding intolerance.
Choice D reason: Encouraging oral intake is not feasible for a client with extensive burns and absent bowel sounds due to the high risk of inadequate intake and aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: A sensation of being cold can occur as the body's circulation diminishes and blood flow to the extremities decreases.
Choice B reason: A heightened sense of hearing is not typically a sign of impending death; this choice is incorrect.
Choice C reason: Difficulty swallowing can be a sign of impending death due to the body's muscles weakening and a decrease in reflexes.
Choice D reason: Tachycardia may occur as the heart tries to compensate for decreased function in other systems.
Choice E reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing, are a common sign of impending death.
Correct Answer is A
Explanation
Choice A reason: Albuterol is a short-acting beta-2 agonist that is used as a quick-relief medication to prevent exercise-induced bronchoconstriction.
Choice B reason: Prednisone is a corticosteroid used for long-term control, not for immediate relief before exercise.
Choice C reason: Montelukast is a leukotriene receptor antagonist used for long-term control and prevention, not typically for immediate pre-exercise use.
Choice D reason: Fluticasone/salmeterol is a combination of a corticosteroid and a long-acting beta-2 agonist, used for long-term control, not for quick relief before exercise.
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