Which of the following clients is most at risk for fluid volume deficit?
1. 25-year-old male near-drowning victim
2. 56-year-old woman with salicylate poisoning
3. 45-year-old woman with second-degree burns over 20% of her body
4. 13-year-old boy with an oral temperature of 103.4° F
ANS: 3
The greater the body surface burned, the greater the fluid loss. The burned client loses body flu-ids by one of five routes. First, plasma leaves the intravascular space and becomes trapped ede-ma. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from dam-aged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume. A near-drowning victim may suf-fer from hypoxia and respiratory acidosis but would not be as likely to be at risk for fluid volume deficit as the burn victim. Salicylate poisoning may cause some insensible fluid loss through the body's hyperventilation to compensate for the increased PaCO2. Adolescents have increased metabolic processes and increased water production because of the rapid changes that occur in the anatomical and physiological process.
You might also like to view...
What appearance should the returned dialysate from a client's manual peritoneal dialysis session have?
a. clear and white c. cloudy and white b. clear and light yellow d. cloudy and dark yellow
Which statement is true about the physiologic effects of pain in labor?
a. It usually results in a more rapid labor. b. It is considered to be a normal occurrence. c. It may result in decreased placental perfusion. d. It has no effect on the outcome of labor.
The community/public health nurse was excited about creating a program for prenatal education and care for single teenage mothers. Before writing an application for a grant to fund the program, what should the nurse determine?
a. Agency's policies about writing grants for such a program b. Number of single teenage mothers in the local high schools c. Whether local teenagers are interested in receiving such a service d. Whether anyone else in the area is offering such a service
A patient is receiving UFH therapy. The nurse instructs the UAP in which task related to the UFH therapy?
a. Observe the skin for ecchymosis, bruising, and petechiae during AM hygiene. b. Replace the antiembolism devices after bathing or ambulating. c. Check on the patient every 2 hours and report changes in mental status. d. Watch for and report blood in the stool when assisting the patient with toileting.