Nokea
A nurse is planning care for a toddler who has burns over 50% total body surface area. Which of the following actions should the nurse include in the plan of care?
- A. Administer enteral feedings
- B. Limit intake of vitamin C
- C. Limit dietary protein
- D. Administer insulin prior to meals
Correct Answer: A
Rationale: Administering enteral feedings is crucial for ensuring adequate nutrition and supporting healing in toddlers with extensive burns. Burns over 50% total body surface area can lead to increased metabolic demands, making it essential to provide nutrition through enteral feedings to meet the child's needs for healing and recovery. Limiting intake of vitamin C or dietary protein would be detrimental in this scenario as the child requires increased amounts of nutrients to support healing. Administering insulin prior to meals is not indicated in this case as the priority is to provide adequate nutrition to promote healing.
You may also like to solve these questions
A nurse is reviewing the medication administration record for a client who is 2 days postoperative following abdominal surgery. The nurse should recognize that which of the following medications places the client at risk for wound dehiscence?
- A. Omeprazole
- B. Zolmitriptan
- C. Prednisone
- D. Verapamil
Correct Answer: C
Rationale: Corrected Rationale: Prednisone is a corticosteroid that can impair wound healing and increase the risk of wound dehiscence. Omeprazole (Choice A) is a proton pump inhibitor used to reduce stomach acid production and does not directly impact wound healing. Zolmitriptan (Choice B) is a medication used to treat migraines and does not affect wound healing. Verapamil (Choice D) is a calcium channel blocker used to treat high blood pressure and certain heart conditions, and it does not pose a significant risk for wound dehiscence.
A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?
- A. Measure the client's gastric residual every 12 hours.
- B. Obtain the client's electrolyte levels every 4 hours.
- C. Keep the client's head elevated at 15° during feedings.
- D. Flush the client's tube with 30 mL of water every 4 hours.
Correct Answer: D
Rationale: Flushing the client's tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client's gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client's electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client's head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.
A healthcare provider is admitting a client who practices Hinduism. The healthcare provider should identify that which of the following foods is prohibited according to Hindu dietary practices?
- A. Pork
- B. Chicken
- C. Beef
- D. Seafood
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?
- A. Stabilize the tube with tape to the newborn's cheek.
- B. Remove supplemental oxygen during the feeding.
- C. Measure the stomach aspirate prior to the feeding.
- D. Place the newborn on their left side for 30 minutes after the feeding.
Correct Answer: C
Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn's cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.
A patient is being cared for by a nurse who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?
- A. Serve foods without sauces or gravies
- B. Offer mouth rinses with normal saline and water
- C. Serve foods while still at a hot temperature
- D. Instruct the client to drink liquids without a straw
Correct Answer: B
Rationale: Offering mouth rinses with normal saline and water is an appropriate intervention for a nurse caring for a patient with stomatitis following radiation treatment. This intervention can help soothe and clean the mouth, promoting comfort and oral hygiene. Choice A is incorrect because serving foods without sauces or gravies does not directly address the client's stomatitis. Choice C is incorrect because serving hot foods can exacerbate discomfort in the client's mouth. Choice D is incorrect because using a straw can help in preventing further irritation in the client's mouth.