The nurse is administering crystalloid fluid replacement to an adult who has experienced severe fluid volume loss. The nurse expects to replace how much normal saline as ordered for each liter of volume loss in the client?
1 liter
2 liters
3 liters
5 liters
The Correct Answer is C
Rationale:
A. Replacing 1 liter of normal saline for each liter of fluid lost is insufficient in cases of severe fluid volume loss. Crystalloids distribute rapidly between the intravascular and interstitial spaces, so a 1:1 replacement ratio does not adequately restore circulating volume.
B. Replacing 2 liters per liter of loss may partially restore intravascular volume but often remains inadequate for severe hypovolemia, especially in trauma or burn patients, because crystalloids only remain in the intravascular space for a short time.
C. Replacing 3 liters of isotonic crystalloid (normal saline or Lactated Ringer’s) per liter of estimated blood or fluid loss is standard practice for adults. This accounts for the distribution of crystalloids: roughly one-third remains in the intravascular compartment while two-thirds shift into the interstitial space. This ratio ensures adequate restoration of circulating volume and perfusion to vital organs.
D. Replacing 5 liters per liter of fluid loss would likely lead to fluid overload and pulmonary edema, making it unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. 53 mm Hg would indicate severe hypotension and does not match the calculation.
B. 86 mm Hg is higher than the calculated value and would suggest better perfusion than reflected by the BP provided.
C. A MAP of 73 mm Hg is the accurate calculation and is just above the minimum MAP of 65 mm Hg needed to maintain adequate organ perfusion.
To calculate mean arterial pressure (MAP), use the formula:
MAP = (Systolic BP + 2 × Diastolic BP) ÷ 3
Substitute the given values:
MAP = (100 + 2 × 60) ÷ 3
MAP = (100 + 120) ÷ 3
MAP = 220 ÷ 3
MAP ≈ 73 mm Hg
D. 110 mm Hg reflects systolic pressure, not MAP.
Correct Answer is D
Explanation
Rationale:
A. Flattened neck veins are not characteristic of cardiac tamponade. In tamponade, venous return to the heart is impaired, leading to distended neck veins (jugular venous distention) rather than flattening.
B. Bradycardia is not typical in cardiac tamponade; patients often exhibit tachycardia as a compensatory response to decreased stroke volume.
C. Sudden lethargy may occur as cardiac output declines, but it is a late and nonspecific sign. Reliance on mental status alone may delay recognition of tamponade.
D. Muffled heart sounds are a hallmark sign of cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of heart sounds, making them difficult to hear on auscultation. This, along with hypotension and jugular venous distention (Beck’s triad), strongly supports the suspicion of cardiac tamponade.
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