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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Taking the medication right before eating breakfast is not an appropriate instruction, as it can reduce the absorption and effectiveness of alendronate, which is a bisphosphonate drug that inhibits bone resorption and increases bone density. The client should take the medication at least 30 min before eating or drinking anything other than water.
Choice B reason: Drinking milk with the medication is not an appropriate instruction, as it can interfere with the absorption and effectiveness of alendronate, which can bind to calcium and other minerals and form insoluble complexes that are excreted in feces. The client should avoid consuming dairy products or supplements that contain calcium, iron, magnesium, or aluminum for at least 30 min after taking the medication.
Choice C reason: Staying upright for 30 to 60 min after taking the medication is an appropriate instruction, as it can prevent esophageal irritation or ulceration that can be caused by alendronate, which can be corrosive to the mucosa if it remains in contact with it for too long. The client should not lie down or bend over until after their first food of the day.
Choice D reason: Chewing the tablets thoroughly is not an appropriate instruction, as it can increase the risk of esophageal irritation or ulceration that can be caused by alendronate, which can be abrasive to the mucosa if it is not swallowed whole with a full glass of water. The client should not crush, break, or dissolve the tablets in any liquid.
Correct Answer is C
Explanation
Choice A reason:This is a requirement for Airborne Precautions (used for smaller particles like those in Tuberculosis, Measles, or Varicella). Pertussis droplets are too large to remain suspended in the air, so a standard surgical mask is sufficient.
Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.
Choice C reason:Pertussis (Whooping Cough) is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. It is transmitted through large respiratory droplets expelled when an infected person coughs or sneezes. Because these droplets are heavy and typically travel only 3 to 6 feet before falling to the ground, Droplet Precautions are required.
Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.
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