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
The correct answer is choice A. Client has an NG tube to gastric suction.
Choice A rationale:
Having an NG tube to gastric suction can lead to hypokalemia because the suctioning process removes potassium from the stomach contents, leading to a decrease in serum potassium levels.
Choice B rationale:
While a history of alcohol abuse disorder can lead to various electrolyte imbalances, it is not the most direct cause of hypokalemia compared to gastric suction.
Choice C rationale:
Drinking 3.5 to 4 liters of water each day can lead to dilutional hyponatremia but is less likely to cause hypokalemia directly.
Choice D rationale:
Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium in the body. Therefore, it is not a causative factor for hypokalemia.
Correct Answer is A
Explanation
Choice A rationale: Patients with bulimia are at increased risk for developing metabolic alkalosis due to recurrent vomiting, which leads to loss of hydrochloric acid from the stomach and results in an elevated blood bicarbonate level.
Choice B rationale: Patients with COPD are more likely to develop respiratory acidosis due to retention of carbon dioxide, not metabolic alkalosis.
Choice C rationale: Patients with venous stasis ulcers do not have a direct association with metabolic alkalosis.
Choice D rationale: Patients on dialysis are more likely to experience metabolic acidosis due to impaired kidney function and inability to excrete acid effectively.
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