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","D","E"]
Explanation
A, D, and E.
Choice A rationale:
Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.
Choice B rationale:
Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.
Choice C rationale:
Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.
Choice D rationale:
Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.
Choice E rationale:
Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.
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.
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