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 B
Explanation
Choice A: This is incorrect because applying petroleum jelly to the client's nares can interfere with oxygen delivery and cause skin breakdown. The nurse should use water-soluble lubricant or saline spray to moisten the nares and prevent dryness from oxygen therapy.
Choice B: This is correct because initiating fall precautions can prevent injury and complications for the client who has aspirated pneumonia and hypoxia. The client may have altered mental status, weakness, or dizziness due to hypoxia, infection, or medications. The nurse should use bed alarms, side rails, and assistive devices as needed.
Choice C: This is incorrect because maintaining the client in a supine position can worsen hypoxia and pneumonia by decreasing lung expansion and increasing secretions. The nurse should elevate the head of the bed at least 30 degrees and encourage frequent position changes to improve ventilation and drainage.
Choice D: This is incorrect because implementing contact precautions is not indicated for the client who has aspirated pneumonia and hypoxia. Aspirated pneumonia is caused by inhalation of foreign material into the lungs, not by transmission of microorganisms from person to person. The nurse should use standard precautions and droplet precautions if the client has a cough or sputum production.
Correct Answer is A
Explanation
Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.
Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.
Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.
Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.
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