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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Metabolic alkalosis.

Choice A rationale:

The given blood gas results show a pH of 7.53, which is alkaline (above the normal range of

7.35 to 7.45), and a high bicarbonate level of 36 mEq/L (normal range is 22 to 26 mEq/L). This combination indicates metabolic alkalosis, a condition where there is an excessive accumulation of bicarbonate in the blood, leading to increased pH.

Choice B rationale:

Metabolic alkalosis is characterized by increased blood bicarbonate levels, which can occur due to conditions like vomiting, diuretic use, or excessive ingestion of bicarbonate-containing substances. It results in symptoms such as muscle twitching, tetany, and respiratory depression.

Choice C rationale:

Respiratory alkalosis is characterized by an elevated blood pH and low carbon dioxide levels (hypocapnia). However, the bicarbonate level is not directly related to respiratory alkalosis, making this choice incorrect based on the given information.

Choice D rationale:

Metabolic acidosis is characterized by a decreased blood pH and low bicarbonate levels. The presented blood gas results show an alkaline pH and high bicarbonate, making this choice incorrect.

A. Effects of rapidly infused intravenous fluids. B. The body's natural compensatory mechanisms. C. Pharmacological effects of a diuretic. D. Cardiac failure.

Correct Answer is B

Explanation

Choice B rationale:

The patient's tachycardia, pale, cool skin, and decreased urine output are signs of the body's natural compensatory mechanisms in response to fluid volume deficit. When the body

experiences a decrease in fluid volume, it tries to compensate by increasing heart rate (tachycardia) to maintain blood flow to vital organs and constricting blood vessels to preserve fluid and maintain blood pressure. Pale, cool skin is a result of vasoconstriction, and decreased urine output is a way the body conserves water during dehydration.

Choice A rationale:

Effects of rapidly infused intravenous fluids are not the cause of the patient's current findings. In fact, the nurse's notes indicate that the IV fluid therapy (0.9% sodium chloride) was initiated at 125 mL/hr, which is a relatively standard and cautious rate. Rapidly infused fluids could potentially cause fluid overload, but that is not the situation here.

Choice C rationale:

Pharmacological effects of a diuretic are not relevant to this patient's presentation. There is no mention of diuretic use in the nurse's notes, and the symptoms presented are more consistent with fluid volume deficit and dehydration rather than diuretic use.

Choice D rationale:

Cardiac failure is not the correct answer, as there is no indication of heart failure in the patient's presentation or nurse's notes. The symptoms and findings described are more indicative of fluid volume deficit, which is not synonymous with cardiac failure.

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The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid-base disorder?

Correct Answer is B

Explanation

A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

Correct Answer is B

Explanation

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

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A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

A patient is diagnosed with hypokalemia. After reviewing the patient's current medications, which drug should the nurse consider that might have contributed to the patient's health problem?

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?