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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.

Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.

Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.

Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.

A. Prone B. Knees elevated C. Lithotomy D. Leaning forward

Correct Answer is D

Explanation

Choice A reason: Prone position is not appropriate for a paracentesis, as it can compress the abdominal organs and make it difficult to access the peritoneal cavity.

Choice B reason: Knees elevated position is not appropriate for a paracentesis, as it can increase the intra-abdominal pressure and reduce the amount of fluid that can be drained.

Choice C reason: Lithotomy position is not appropriate for a paracentesis, as it can expose the genital area and increase the risk of infection or injury.

Choice D reason: Leaning forward position is appropriate for a paracentesis, as it can shift the abdominal organs upward and allow more space for the needle insertion and fluid drainage.

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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?

Nursing Test Bank

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