Correct Answer: A

Rationale: Following an escharotomy for burn injuries, patients should be taught to monitor for infection and care for the incision site. Choice A is the correct answer because infection is a common risk after a procedure involving incisions. Choices B, C, and D are incorrect. Restricting fluid intake is not typically advised after an escharotomy; avoiding physical activity may vary depending on the individual's condition and should be guided by healthcare providers; and limiting phosphorus to 1,500 mg/day is not directly related to post-escharotomy care.

Correct Answer: A

Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.

Correct Answer: A

Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.

Correct Answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, tightening the connections of the chest tube system is the appropriate intervention. This action can often resolve an air leak, which is the common cause of continuous bubbling. Clamping the chest tube or replacing it is not recommended as the first-line intervention because it may lead to complications or unnecessary tube changes. Continuing to monitor the chest tube without addressing the air leak would delay necessary corrective action, potentially causing respiratory compromise in the patient. Therefore, tightening the connections of the chest tube system is the most suitable initial step to manage continuous bubbling in the water seal chamber.

Correct Answer: A

Rationale: The correct answer is to limit phosphorus intake to 700 mg/day for a patient with pre-dialysis end-stage kidney disease. Excess phosphorus can lead to complications such as bone and heart issues in these patients. Increasing protein intake (Choice B) is generally not recommended as it can lead to increased waste production that the kidneys may struggle to eliminate. Restricting sodium intake (Choice C) is important for managing blood pressure, but the recommendation is usually higher than 1 g/day. Increasing potassium intake (Choice D) is not typically advised in patients with kidney disease, as they often need to limit potassium due to impaired kidney function.