Practice Quiz

NCLEX-RN

Category - Physiological

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The nurse is caring for a client with a third-degree circumferential arm burn. Which of the following demonstrates appropriate nursing care for this client during the resuscitative phase?
  1. Elevation of the arms on pillows above the level of the heart
  2. Administration of oral pain medications
  3. Providing a diet low in protein and high in carbohydrates, fats, and vitamins
  4. Increasing the rate of IV fluid resuscitation if the hemoglobin and hematocrit levels decrease, as ordered
Explanation
Answer: A - Elevation of the arms on pillows decreases the risk for dependent edema. Oral medications are often avoided because of the possibility of gastrointestinal dysfunction. Protein is needed for tissue repair; therefore, the client should be offered foods high in protein. The rate of infusion is decreased in cases where the hemoglobin and hematocrit levels are low to meet the client’s perfusion needs.
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