The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?
Intracellular fluid deficit.
Interstitial fluid deficit.
Intracellular fluid overload.
Extracellular fluid deficit.
The Correct Answer is D
Extracellular fluid deficit.
Choice A rationale:
Intracellular fluid deficit is a decrease in the fluid inside the cells, which may occur in conditions such as diabetic ketoacidosis. Severe burns are more likely to cause extracellular fluid shifts rather than intracellular fluid deficits.
Choice B rationale:
Interstitial fluid deficit involves a decrease in fluid in the interstitial spaces between cells. While burns can lead to fluid shifts, the primary concern is fluid loss from the vascular space (extracellular fluid).
Choice C rationale:
Intracellular fluid overload is not a typical health problem associated with severe burns. Burn injuries are more likely to cause fluid loss and shifts out of the intracellular space.
Choice D rationale:
Severe burns can result in significant loss of plasma and extracellular fluid, leading to hypovolemia and extracellular fluid deficit. This fluid loss can lead to hypovolemic shock and other complications if not adequately managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Urine specific gravity 1.020.
Choice A rationale:
Urine specific gravity is a measure of urine concentration, indicating the ability of the kidneys to concentrate or dilute urine. A specific gravity of 1.020 falls within the normal range (typically 1.010 to 1.030). An appropriate specific gravity indicates that the client's kidneys are responding well to the IV fluids, maintaining adequate urine output and concentration.
Choice B rationale:
Potassium level of 5.2 mEq/L is above the normal range of 3.5 to 5 mEq/L. However, this value does not specifically indicate whether the client is responding effectively to the IV fluids for dehydration.
Choice C rationale:
Hct (Hematocrit) of 6296 is not a valid measurement; it appears to be a typographical error or an incomplete value. Therefore, it cannot be used to assess the client's response to treatment.
Choice D rationale:
Sodium level of 165 mEq/L is elevated beyond the normal range of 136 to 145 mEq/L. However, this value does not provide information about the client's response to IV fluids for dehydration.
Correct Answer is A
Explanation
Choice A rationale:
The arterial blood gas results show a low pH (acidosis) and an elevated Paco2 (partial pressure of carbon dioxide), which indicates respiratory acidosis. This condition occurs when there is inadequate removal of carbon dioxide through ventilation, leading to an accumulation of carbonic acid in the blood and a decrease in pH.
Choice B rationale:
Metabolic acidosis would present with a low pH and a low bicarbonate (HCO3-) level, not an elevated Paco2.
Choice C rationale:
Metabolic alkalosis would present with a high pH and an elevated bicarbonate (HCO3-) level, not an elevated Paco2.
Choice D rationale:
Respiratory alkalosis would present with a high pH and a decreased Paco2, not an elevated Paco2 as seen in this case.
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