The nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which of the following clients has the least risk for developing third-spacing of fluid?
1. Client with a major burn
2. Client with an ischemic stroke
3. Client with Laënnec's cirrhosis
4. Client with chronic renal failure
2
Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, ma-jor trauma, burns, sepsis, major surgery, malignancy, gastrointestinal (GI) malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third-spacing.
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