The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance?
Metabolic alkalosis
Hypermagnesemia
Hypercalcemia
Hypovolemia
The Correct Answer is D
A. Metabolic alkalosis is not a direct result of third spacing and is more often associated with vomiting or diuretic use.
B. Hypermagnesemia occurs with excessive intake or renal failure, not third spacing.
C. Hypercalcemia is unrelated to fluid shifts associated with burns.
D. Hypovolemia is the correct answer. Third spacing occurs when fluid shifts from the intravascular space to interstitial or "third" spaces, leading to a decrease in circulating blood volume despite normal or increased total body fluid — causing signs of hypovolemia such as hypotension, tachycardia, and decreased urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Diuretics are used to manage fluid overload and ascites, not ammonia levels.
B. Fluid restriction may be necessary in cases of hyponatremia but does not lower ammonia levels.
C. Reducing protein intake helps decrease ammonia production, since protein breakdown in the gut contributes to ammonia formation, which the impaired liver cannot detoxify effectively.
D. Vitamin K is given to improve clotting in liver disease but does not affect ammonia metabolism.
Correct Answer is D
Explanation
A. Mobilization is important but not the primary intervention for ascites.
B. Beta-blockers are used to manage portal hypertension but are not the first priority in ascites management.
C. Vitamin B12 injections are unrelated to ascites.
D. Diuretics help reduce fluid accumulation by promoting sodium and water excretion, which is essential in managing ascites.
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