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"]
Explanation
Choice A reason: A universal dropper ensures accurate dosing, which is crucial for infants due to their small size and the precise dosing required for their medications.
Choice B reason: Adding medication to a formula bottle is not recommended because if the infant does not finish the bottle, they will not receive the full medication dose.
Choice C reason: Flavoring can help mask the taste of medications, making it easier for infants to take them, which is especially useful if the medication has an unpleasant taste.
Choice D reason: Using the nipple of a bottle can be an effective way to administer medication to an infant who is used to bottle-feeding, as it can make the process more familiar and comfortable.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.
Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.
Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.
Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.
Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.
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