A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?

Place the client on a low-carbohydrate diet.

Monitor the client's calorie intake daily.

Place the client on strict bed rest.

Weigh the client once per week.

Answer and Explanation

The Correct Answer is B

A) Place the client on a low-carbohydrate diet:
A low-carbohydrate diet is not appropriate for a client with full-thickness burns, as their nutritional needs are significantly increased due to the high metabolic demands of wound healing. A high-calorie, high-protein diet is usually recommended to support recovery and manage the increased energy expenditure associated with burn injuries.

B) Monitor the client's calorie intake daily:
Daily monitoring of calorie intake is crucial for clients with significant burn injuries. Burns increase metabolic demands, and the client’s nutritional needs must be closely tracked to ensure adequate caloric and protein intake, which is essential for wound healing and overall recovery. Regular monitoring helps adjust dietary needs as required.

C) Place the client on strict bed rest:
Strict bed rest is not indicated for clients with burns, as mobility and physical therapy are important for maintaining muscle strength and preventing complications like contractures. While rest is important, a balanced approach involving gradual mobilization is preferred to support functional recovery.

D) Weigh the client once per week:
Weekly weighing may not be frequent enough for clients with burn injuries, as their weight can fluctuate significantly due to changes in fluid status and nutritional needs. More frequent monitoring is necessary to ensure that the client is receiving adequate nutrition and to assess their overall progress.

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Correct Answer is C

Explanation

A. Remove one of the weights:
Removing a weight from skeletal traction can compromise the effectiveness of the traction, potentially leading to improper alignment and healing of the fracture. The weights are essential for maintaining the proper alignment and stability of the fractured bone, so altering them without proper medical guidance is not advisable.

B. Tie knots in the ropes near the pulleys to shorten them:
Tying knots in the ropes to shorten them is not a safe or appropriate method for adjusting traction. It can lead to uneven force distribution, poor alignment, and potential injury. Traction adjustments should be made by qualified personnel using proper equipment and methods.

C. Pull the client up in bed:
Pulling the client up in bed helps to ensure that the weights are properly suspended and not resting on the floor. This action helps maintain the effectiveness of the skeletal traction by ensuring that the appropriate amount of force is applied to the fracture. It also prevents potential complications associated with improperly positioned weights.

D. Increase the elevation of the affected extremity:
Increasing the elevation of the affected extremity might be indicated to reduce swelling or improve comfort but does not address the issue of weights resting on the floor. Proper positioning of the weights is crucial for effective traction and must be corrected to ensure optimal treatment outcomes.

A. "I will use canola oil when making salad dressing." B. "I will drink whole milk with my cereal." C. "I will increase my intake of canned vegetables." D. "I will limit my portions of meat to 8 ounces."

Correct Answer is A

Explanation

A. "I will use canola oil when making salad dressing.":
Canola oil is a good choice for clients with cardiovascular disease as it is low in saturated fats and high in monounsaturated fats, which can help improve lipid profiles and reduce the risk of heart disease. This choice aligns with dietary recommendations to use healthier fats.

B. "I will drink whole milk with my cereal.":
Whole milk is high in saturated fats, which can contribute to elevated cholesterol levels and increase the risk of cardiovascular disease. Clients with cardiovascular issues are typically advised to choose lower-fat or fat-free dairy products to help manage their condition.

C. "I will increase my intake of canned vegetables.":
Canned vegetables often contain high levels of sodium, which can contribute to hypertension and worsen cardiovascular disease. It's generally recommended to choose fresh or frozen vegetables with no added salt or to look for low-sodium canned options.

D. "I will limit my portions of meat to 8 ounces.":
While portion control is important, the focus should be on the type of meat consumed. For cardiovascular health, it's advisable to choose lean meats and to limit red and processed meats, rather than just focusing on portion size. A more heart-healthy approach would involve incorporating more plant-based proteins and lean poultry or fish.

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A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?

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