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

Choice A rationale:

A phosphorus level of 4.5 mEq/L falls within the normal range, which is typically between 2.5 to 4.5 mEq/L. Although it's essential to monitor phosphorus levels, it is not the priority finding in this scenario.

Choice B rationale:

A potassium level of 2.9 mEq/L is the priority finding. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac arrhythmias and muscle weakness. Immediate intervention is necessary to address the potassium imbalance.

Choice C rationale:

A calcium level of 8.2 mg/dL falls within the normal range (typically 8.5 to 10.2 mg/dL). While calcium levels are essential to monitor, they do not take precedence over the critically low potassium level in this situation.

Choice D rationale:

A sodium level of 145 mEq/L falls within the normal range, which is usually around 135 to 145 mEq/L. Although monitoring sodium levels is important, it is not the priority finding when compared to the critically low potassium level.

A. The client who has end-stage renal failure and is scheduled for dialysis today. B. The client who has been NPO since midnight for endoscopy. C. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. D. The client who has gastroenteritis and is febrile.

Correct Answer is D

Explanation

The correct answer is choice D. The client who has gastroenteritis and is febrile.

Choice A rationale:

The client with end-stage renal failure scheduled for dialysis would not be at risk for fluid volume deficit because dialysis is a treatment that removes waste, salt, and extra water to prevent them from building up in the body, keeping a safe level of certain chemicals in the blood, and controlling blood pressure.

Choice B rationale:

Being NPO (nothing by mouth) since midnight for endoscopy typically involves a short period of fasting. While it could potentially contribute to a mild fluid volume deficit, it is not as significant as other causes like vomiting or diarrhea, which can lead to more substantial fluid losses.

Choice C rationale:

A client with left-sided heart failure and an elevated BNP level is more likely to experience fluid volume overload rather than a deficit. BNP is released in response to ventricular volume expansion and pressure overload, which are indicative of heart failure, not fluid volume deficit.

Choice D rationale:

The client with gastroenteritis and a fever is at risk for fluid volume deficit due to increased fluid losses from vomiting, diarrhea, and fever-induced perspiration. These symptoms align with the common risk factors for fluid volume deficit, which include vomiting, diarrhea, and sweating.

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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 nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

Correct Answer is B

Explanation

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

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The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?

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