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 C

Explanation

Choice A rationale:

Patients with bulimia are at risk of developing metabolic alkalosis due to repeated episodes of vomiting, which leads to a loss of stomach acid (hydrochloric acid) and an increase in bicarbonate levels. However, this choice is not the correct answer for this question.

Choice B rationale:

Patients with COPD (Chronic Obstructive Pulmonary Disease) are at risk of developing respiratory acidosis, not metabolic alkalosis. In COPD, there is impaired lung function, leading to retention of carbon dioxide and increased levels of carbonic acid in the blood.

Choice C rationale:

Patients with venous stasis ulcer may be at increased risk for developing metabolic alkalosis due to prolonged immobilization. Venous stasis can lead to reduced venous return, which may cause the kidneys to conserve bicarbonate and increase its levels in the blood, resulting in metabolic alkalosis.

Choice D rationale:

Patients on dialysis can experience metabolic imbalances, but they are more likely to develop metabolic acidosis due to the inability of the kidneys to excrete acids effectively.

A. Sodium level. B. Tissue turgor. C. Daily weight. D. Intake and output.

Correct Answer is C

Explanation

Choice A rationale:

Sodium level is a laboratory parameter that can be helpful in assessing fluid balance, but it does not directly measure fluid retention. Abnormal sodium levels may indicate fluid imbalances, but it is not the most reliable measure of fluid retention.

Choice B rationale:

Tissue turgor refers to the skin's elasticity, and it can be used to assess dehydration rather than fluid retention. Poor turgor may indicate dehydration, but it does not specifically measure fluid volume increase.

Choice C rationale:

Daily weight is a reliable measure of fluid retention. An increase in weight over a short period may indicate fluid accumulation in the body, while a decrease in weight could signify fluid loss. It is essential to monitor weight consistently under standardized conditions (e.g., same time, same clothing) for accurate assessment.

Choice D rationale:

Intake and output records provide information about fluid intake and output but may not always reflect fluid retention accurately. It is helpful for assessing fluid balance, but daily weight is a more direct and reliable measure of fluid retention.

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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

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?

Correct Answer is C

Explanation

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?

Correct Answer is C

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?

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?

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a Paco2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select All that Apply.).

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

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?

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?

The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Select all that apply.