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 A

Explanation

Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.

Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.

Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.

Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.

A. Complete breast self-examinations one week prior to menstruation. B. Expect clear discharge from the nipples. C. Consume a diet high in antioxidants. D. Include meats grilled over high heat in the diet.

Correct Answer is C

Explanation

The correct answer is C. Consume a diet high in antioxidants.

Choice A: Complete breast self-examinations one week prior to menstruation.

Performing breast self-examinations one week prior to menstruation is not recommended. The best time to perform a breast self-exam is about 3 to 5 days after your period starts, when your breasts are least likely to be tender or swollen. This timing helps in detecting any unusual changes more accurately.

Choice B: Expect clear discharge from the nipples.

While some nipple discharge can be normal, it is not something that should be expected as a routine part of breast health. Clear, yellow, or white discharge can occur due to hormonal changes, but any spontaneous discharge, especially if it is bloody or from one breast, should be evaluated by a healthcare provider.

Choice C: Consume a diet high in antioxidants.

Consuming a diet high in antioxidants is beneficial for overall health and may help reduce the risk of various diseases, including cancer. Antioxidants help neutralize free radicals, which can damage cells and contribute to cancer development. Foods rich in antioxidants include fruits, vegetables, nuts, and whole grains.

Choice D: Include meats grilled over high heat in the diet.

Including meats grilled over high heat in the diet is not advisable for someone concerned about cancer risk. Grilling meats at high temperatures can produce carcinogens such as heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs), which have been linked to an increased risk of cancer. Therefore, it is better to avoid or limit the consumption of grilled meats.

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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?

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