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","C","E"]

Explanation

Choice A rationale:

Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.

Choice B rationale:

Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.

Choice C rationale:

Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.

Choice D rationale:

Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.

Choice E rationale:

Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.

A. 1000 milliliters. B. 600 milliliters. C. 1200 milliliters. D. 750 milliliters.

Correct Answer is B

Explanation

The correct answer is B. 600 milliliters.

Choice A rationale:

A 24-hour urine output of 1000 milliliters is within the normal range for an adult, indicating adequate kidney function and hydration.

Choice B rationale:

A 24-hour urine output of 600 milliliters is below the normal range (typically 800-2000 milliliters), which may indicate oliguria (reduced urine output) and could be a sign of renal impairment or dehydration. This warrants notifying the healthcare provider.

Choice C rationale:

A 24-hour urine output of 1200 milliliters is also within the normal range, suggesting normal kidney function and hydration status.

Choice D rationale:

A 24-hour urine output of 750 milliliters is slightly below the normal range but may not be immediately concerning unless accompanied by other symptoms. However, it is still important to monitor and possibly notify the healthcare provider if it persists.

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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?

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Naxlex Comprehensive Predictor Exams

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?

Correct Answer is B

Explanation

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