Patients who have sustained a severe burn injury and have an impaired intestinal mucosal barrier are at an increased risk for infection
The implementation of which of the following interventions will 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
Ans: A
Feedback: If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria.
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When discussing family tasks with a client, the nurse identifies integrating new family members as a task of which family stage?
1. Early childbearing 2. Families with preschool children 3. Families with teenagers 4. Families of middle years
When assessing the respiratory status of a client, the nurse should auscultate the lungs by:
1. Listening to breath sounds in the anterior and posterior lung bases. 2. Checking breath sounds in the anterior and posterior thorax. 3. Listening for air exchange in the bronchus and anterior lobes. 4. Checking for adventitious sounds while having the client cough.
Which of the following laboratory findings, would be identified by the nurse as the greatest risk for a cancer client scheduled for implantable port?
A) White blood cell count 10,800/mm3 B) Hemoglobin 10 g/dL C) Hematocrit 36.0% D) Platelet count 98,000/mm3
Which intervention will the nurse consider to be a central responsibility when planning for culturally competent treatment?
a. Learn what the illness means to the patient and how the patient's beliefs can help mediate the stressors. b. Learn as much as possible regarding the beliefs of both the patient and the patient's extended family. c. Ask the patient about beliefs in a formal organized religion and daily or weekly religious practices that can be factored into treatment. d. Tell the patient that it will be important to examine together the belief systems of both the nurse and patient to be sure that they are congruent.