Fluid and Fluid Imbalances
The nurse is caring for a patient with a severed limb who was involved in a motorcycle accident. A tourniquet was placed on the limb before transport to the hospital, but the blood loss was significant. Which solution should the nurse infuse at a high rate of administration? - 0.9% Sodium Chloride - 0.45% Sodium Chloride - D5% 0.45% Sodium Chloride - 3% Sodium Chloride
Correct - 0.9% Sodium Chloride Rationale: Since there was a large blood loss, it is expected that the patient is severely hypovolemic. An isotonic solution is needed to restore the vascular volume. Incorrect - 0.45% Sodium Chloride Rationale: This solution is hypotonic and will shift fluid out of the vessels into the cells, decrease perfusion Incorrect - D5% 0.45% Sodium Chloride Rationale: This hypersonic solution will shift fluid back in to circulation if the cells are wet. This patient had normovolemia prior to this event, so the cells are not overloaded with fluid. Incorrect - 3% Sodium Chloride Rationale: This solution is strongly hypertonic and will cause the patient to become very compromised
The nurse is delivering 0.9% NaCl at 100 mL/hr to a patient admitted yesterday. Which assessment change should the nurse report to the healthcare provider? Bilateral crackles in the lungs Blood pressure of 112/76 mm Hg Pain at the IV site Increased urine output
Correct - Bilateral crackles in the lungs Rationale: Crackles indicate that fluid has shifted into the bases of the lungs, which can create oxygenation problems. A focused respiratory assessment should be completed before notifying the provider. Incorrect - Blood pressure of 112/76 mm Hg Rationale: This is a normal finding and not a concern. Incorrect - Pain at the IV site Rationale: This is not something that needs to be reported; the nurse can make decisions about the IV. Incorrect - Increased urine output Rationale: This would be anticipated for a patient that is properly been hydrated.
The nurse is caring for a patient with tachycardia and hypotension secondary to polyuria from hyperglycemia. Which prescriptions on the medication administration record should the nurse implement? Select all that apply. - 0.9% NaCl 1000 mL over 2 hours - Albumin 25 g in 100 mL intravenously over 4 hours. One dose only - Mannitol 20 g intravenously. One dose only - 0.45% NaCl at 100 mL/hr intravenously - D50.9% NaCl at 50 mL/hr intravenously
Correct: - 0.9% NaCl 1000 mL over 2 hours Rationale: This is an isotonic solution that will increase the amount of fluid in the vascular space and raise the blood pressure. - Albumin 25 g in 100 mL intravenously over 4 hours. One dose only Rationale: Albumin is a colloid protein that pulls fluid from the extravascular to the intravascular space because of its high oncotic pressure. It will increase the blood pressure and improve perfusion. Incorrect: - Mannitol 20 g intravenously. One dose only Rationale: This is an osmotic diuretic that will eliminate excess fluid from the body through the kidney. Giving this would worsen the hypovolemia. - 0.45% NaCl at 100 mL/hr intravenously Rationale: This is a hypotonic solution that would move the fluid out of the vessels into the cells. Hypotension is a sign of hypovolemia in the vessels, so this is not recommended. - D50.9% NaCl at 50 mL/hr intravenously Rationale: This is a hypertonic solution that shifts fluid into circulation if the cells are overloaded with fluid. In this case the cells are dry.
A patient has 3+ pedal and periorbital edema and a normal blood pressure. After reviewing the medication administration record, the nurse recognizes that which prescriptions will reduce the edema? Select all that apply. - 0.9% NaCl 500 mL over 2 hours for SBP <90 mm Hg - Albumin 25 g in 100 mL intravenously over 4 hours. One dose only - Furosemide 40 mg intravenously. One dose only - Compression stockings - KCl 10 mEq in 100 mL 0.9% NaCl intravenously over 2 hours
Correct: - Albumin 25 g in 100 mL intravenously over 4 hours. One dose only Rationale: Albumin is a colloid protein that pulls fluid from the extravascular to the intravascular space because of its high oncotic pressure - Furosemide 40 mg intravenously. One dose only Rationale: This is a loop diuretic that will eliminate excess fluid from the body through the kidney, reducing edema - Compression stockings Rationale: The use of compression stockings will reduce dependent edema from elevated hydrostatic pressure in the lower extremities Incorrect: - 0.9% NaCl 500 mL over 2 hours for SBP <90 mm Hg Rationale: this is an isotonic solution that will keep the fluid in the vascular space and not shift it from the cells to reduce edema. - KCl 10 mEq in 100 mL 0.9% NaCl intravenously over 2 hours Rationale: Potassium replacement will not have an impact on the edema.
A patient comes into the emergency department after being knocked unconscious from a car accident. He is disoriented and is vomiting. The CT scan shows cerebral edema. Which fluid should the nurse request from the practitioner for rehydration? 5% D5W Lactated Ringer's D5 0.45% NaCl 5% Albumin
Incorrect - 5% D5W Rationale: This hypotonic solution will shift fluid out of the vessels into the cells, which would increase the cerebral edema, making the condition worse. Incorrect - Lactated Ringer's Rationale: Lactated Ringer's (LR) is an isotonic solution that creates no fluid shift. Although it would rehydrate the patient, who may be dehydrated from vomiting, it would not improve the cerebral edema. Correct - D5 0.45% NaCl Rationale: This hypertonic solution will move the fluid from the cells into the vascular space, decreasing cerebral edema and increasing vascular hydration. Incorrect - 5% Albumin Rationale: This colloid will increase vascular volume but not decrease the cerebral edema.
A registered nurse is caring for a patient experiencing fluid volume excess. Which assessment finding is anticipated? - Dry mucous membranes - oliguria - Concentrated urine output - Edema
Incorrect - Dry mucous membranes Rationale: A patient suffering from hypovolemia is known to experience severe thirst and have dry mucous membranes. Incorrect - Oliguria Rationale: Oliguria is a very common clinical manifestation found in patients suffering from hypovolemia. Incorrect - Concentrated urine output - Incorrect Rationale: Patients with hypovolemia are known to have concentrated urine output. Correct -Edema Rationale: Edema is a sign of excess fluid outside the vascular space, in the tissues. Test Taking Tips:Differentiate between excess and deficit.
The nurse is preparing a healthy patient for an elective outpatient surgery. The provider tells the nurse to, "Go ahead and start an IV with some fluids, I'll be back in 30 minutes to take the patient to surgery," then hangs up the phone. What should the nurse do next? - Hang a bag of 0.9% NaCl at a low rate. - Start the IV but do not start a solution. - Contact the provider back to obtain a complete order. - Do not do anything since the surgery is in 30 minutes and the patient is healthy.
Incorrect - Hang a bag of 0.9% NaCl at a low rate. Rationale: It is outside the nurse's scope of practice to begin a solution without a proper order from the healthcare provider. Incorrect - Start the IV but do not start a solution. Rationale: This could lead to a patient going to surgery who lacks proper hydration, leading to complications. Correct - Contact the provider back to obtain a complete order. Rationale: This is the best option since the order received was incomplete. Incorrect - Do not do anything since the surgery is in 30 minutes and the patient is healthy. Rationale: This will cause a delay in the surgical procedure if nothing is done ahead of time. Test Taking Tips:The nurse must always obtain a complete, accurate, and appropriate order.
The nurse is caring for a patient with a bowel obstruction who has been vomiting at home for 3 days before coming to the hospital. Which priority prescription should the nurse request when contacting the healthcare provider? - Hydroxyethyl starch (HES) - Lactated Ringer's - Dextran - Mannitol
Incorrect - Hydroxyethyl starch (HES) Rationale: This is a colloid that will create vascular expansion, but it should not be delivered until a crystalloid is given. Correct - Lactated Ringer's Rationale: Lactated Ringer's (LR) is an isotonic solution that creates no fluid shift. It works well to increase vascular volume when the patient is dehydrated from vomiting. Incorrect - Dextran Rationale: This is a colloid that will create vascular expansion, but it should not be delivered until a crystalloid is given. Incorrect - Mannitol Rationale: This is an oliguric diuretic that, if given, will cause a loss of fluid making the patient more dehydrated. Test Taking Tips:Before a colloid can be considered, a crystalloid should be given first.
The nurse is caring for a patient with ascites from liver failure receiving IV albumin. What response will the nurse anticipate if the medicine is effective? - Peripheral edema will increase. - Urine output will decrease. - Blood pressure will decrease. - Abdominal girth will decrease.
Incorrect - Peripheral edema will increase. Rationale: Albumin will pull fluid from the extravascular to the intravascular space, therefore decreasing edema. Incorrect - Urine output will decrease. Rationale: Urine output will increase with the delivery of albumin due to increased perfusion in the vascular space and to the kidneys. Incorrect - Blood pressure will decrease. Rationale: As fluid moves from the third space to the vascular space, the blood pressure would increase. Correct - Abdominal girth will decrease. Rationale: Albumin will pull fluid from the abdominal cavity into the vascular space, decreasing the abdominal girth and ascites fluid. Test Taking Tips:The fluid compartment in ascites is considered the third space, like synovial and pericardial fluid.
An older adult patient is admitted to the emergency department for hypovolemia. After 500 mL of 0.9% NaCl is delivered intravenously over 1 hour, the assessment shows: blood pressure of 167/88 mm Hg, heart rate 110 beats per minute, and crackles bilaterally. What should the nurse determine from this situation? - The patient has been properly rehydrated. - The patient continues to be hypovolemic. - The patient is showing signs of hypervolemia. - The patient is showing no change in condition.
Incorrect - The patient has been properly rehydrated. Rationale: Hypertension, tachycardia, and crackles are signs of hypervolemia; therefore, proper rehydration did not take place. Incorrect - The patient continues to be hypovolemic. Rationale: The hypertension, tachycardia, and crackles are signs of hypervolemia. If the patient continued to have hypovolemia, they would be hypotensive, tachycardic, and without crackles. Correct - The patient is showing signs of hypervolemia. Rationale: This is correct. These assessment changes demonstrate that too much fluid was given too quickly. The fluid needs to be stopped and the provider needs to be notified. Incorrect - The patient is showing no change in condition. Rationale: These symptoms demonstrate excess fluid has been given and the patient is no longer hypovolemic. Test Taking Tips:Consider older adult variations.