Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?
A. Intracellular fluid deficit.
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.
B. Interstitial fluid deficit.
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).
C. Intracellular fluid overload.
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.
D. Extracellular fluid deficit.
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI custom Fluid and Electrolyte Exam Summer 2023 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.).
A. Lethargy.
Lethargy is a common symptom of metabolic alkalosis due to the body’s attempt to compensate for the altered pH balance, leading to decreased energy levels and fatigue.
B. Kussmaul's respirations.
Kussmaul’s respirations are typically associated with metabolic acidosis, not alkalosis. These deep, labored breaths are the body’s way of trying to expel excess carbon dioxide to correct acidosis.
C. Circumoral paresthesia.
Circumoral paresthesia, or tingling around the mouth, is a symptom of metabolic alkalosis. This occurs due to changes in calcium ion concentration affecting nerve function.
D. Bicarbonate excess.
Bicarbonate excess is a direct cause of metabolic alkalosis. Elevated bicarbonate levels in the blood lead to an increased pH, resulting in alkalosis.
E. Flushing
Flushing is not a typical symptom of metabolic alkalosis. It is more commonly associated with conditions that cause vasodilation or increased blood flow to the skin.
Full Explanation
The correct answer is choice A, C, and D.
Choice A rationale:
Lethargy is a common symptom of metabolic alkalosis due to the body’s attempt to compensate for the altered pH balance, leading to decreased energy levels and fatigue.
Choice B rationale:
Kussmaul’s respirations are typically associated with metabolic acidosis, not alkalosis. These deep, labored breaths are the body’s way of trying to expel excess carbon dioxide to correct acidosis.
Choice C rationale:
Circumoral paresthesia, or tingling around the mouth, is a symptom of metabolic alkalosis. This occurs due to changes in calcium ion concentration affecting nerve function.
Choice D rationale:
Bicarbonate excess is a direct cause of metabolic alkalosis. Elevated bicarbonate levels in the blood lead to an increased pH, resulting in alkalosis.
Choice E rationale:
Flushing is not a typical symptom of metabolic alkalosis. It is more commonly associated with conditions that cause vasodilation or increased blood flow to the skin.
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.
A. Dysrhythmias.
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.
B. Kussmaul respirations.
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.
C. Weakness.
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
D. Cold, clammy skin.
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
E. Tachycardia
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.
Full 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 patient has a serum phosphate level of 2.0 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Select all that apply.
A. Normal saline.
Normal saline is not typically used to treat low phosphate levels. It is often used to treat dehydration and electrolyte imbalances that do not include hypophosphatemia.
B. Potassium phosphate.
Potassium phosphate is used to treat low phosphate levels. It directly supplements phosphate levels in the body, making it an appropriate treatment for hypophosphatemia.
C. Additional milk intake.
Additional milk intake can help increase phosphate levels, as milk is a good source of phosphate. This is a suitable recommendation for a patient with low phosphate levels.
D. Increased Vitamin D intake.
Increased Vitamin D intake can enhance phosphate absorption from the gastrointestinal tract, making it a beneficial treatment for a patient with low phosphate levels.
Full Explanation
The correct answers are Choices B, C, and D.
Choice A rationale: Normal saline is not typically used to treat low phosphate levels. It is often used to treat dehydration and electrolyte imbalances that do not include hypophosphatemia.
Choice B rationale: Potassium phosphate is used to treat low phosphate levels. It directly supplements phosphate levels in the body, making it an appropriate treatment for hypophosphatemia.
Choice C rationale: Additional milk intake can help increase phosphate levels, as milk is a good source of phosphate. This is a suitable recommendation for a patient with low phosphate levels.
Choice D rationale: Increased Vitamin D intake can enhance phosphate absorption from the gastrointestinal tract, making it a beneficial treatment for a patient with low phosphate levels.