Nokea
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
- A. Early enteral feeding
- B. Administration of prophylactic antibiotics
- C. Bowel cleansing procedures
- D. Administration of stool softeners
Correct Answer: A
Rationale: Early enteral feeding supports the intestinal mucosal barrier, reducing permeability and preventing endotoxin translocation. Prophylactic antibiotics risk resistant bacteria, and bowel cleansing or stool softeners do not address this issue.
You may also like to solve these questions
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
- A. 4 to 6 hours a day for 6 months
- B. During waking hours for 2 to 3 months after the injury
- C. Continuously
- D. At night while sleeping for a year after the injury
Correct Answer: C
Rationale: Elastic pressure garments should be worn continuously (23 hours/day) to minimize scarring and contractures, typically for months until scars mature.
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
- A. Activity Intolerance
- B. Anxiety
- C. Ineffective Coping
- D. Acute Pain
Correct Answer: D
Rationale: Acute pain is a priority in deep partial-thickness burns due to its severity, impacting recovery and contributing to anxiety or coping issues. Pain management often precedes addressing other diagnoses.
A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
- A. Promote truthful communication.
- B. Avoid asking the patient to make decisions.
- C. Teach the patient coping strategies.
- D. Administer benzodiazepines as ordered.
- E. Provide positive reinforcement.
Correct Answer: A,C,E
Rationale: Promoting truthful communication, teaching coping strategies, and providing positive reinforcement foster effective coping by building trust and skills. Decision-making supports autonomy, and benzodiazepines address anxiety, not coping.
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?
- A. 2 days
- B. 3 days
- C. 5 days
- D. 1 week
Correct Answer: A
Rationale: Upper airway edema from burns can develop up to 48 hours post-injury due to inflammation and fluid shifts, requiring vigilant monitoring. Later onset is less likely.
While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior?
- A. The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior.
- B. The patient may be experiencing neurologic or psychiatric complications of his injuries.
- C. The patient may be experiencing inconsistencies in the care that he is being provided.
- D. The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
Correct Answer: D
Rationale: Anger is common in burn patients and may be deflected toward caregivers. Drug reactions, complications, or care inconsistencies are less likely without specific evidence.