Which of the following statements regarding hypertonic (3%) sodium chloride is correct?
Hypertonic fluids are contraindicated in patients with cerebral edema.
Hypertonic saline may be administered to shift fluid out of brain tissue.
Hypertonic saline is most often used for clients in hypernatremia.
Hypertonic fluids are administered to promote increased brain tissue hydration.
The Correct Answer is B
A. Hypertonic fluids are not contraindicated in patients with cerebral edema. In fact, they are often used to reduce cerebral swelling by drawing fluid out of the brain tissue into the bloodstream.
B. Hypertonic saline (3%) is used to shift fluid out of brain tissue in conditions such as cerebral edema. It creates an osmotic gradient, pulling water from the intracellular space into the extracellular and vascular compartments, reducing intracranial pressure.
C. Hypertonic saline is not used for clients with hypernatremia because it would exacerbate the condition by further increasing sodium levels.
D. Hypertonic fluids do not promote hydration of brain tissue. Instead, they work to reduce excess fluid in the brain by creating an osmotic effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.
Correct Answer is ["A","B","C"]
Explanation
A. Jugular vein distention is a common sign of fluid volume overload, as increased central venous pressure causes distention of the jugular veins.
B. Crackles heard during auscultation indicate pulmonary congestion or edema, a hallmark of fluid volume overload.
C. Dyspnea results from fluid accumulation in the lungs, impairing oxygen exchange and causing difficulty breathing.
D. Hypotension is not a sign of hypervolemia; instead, hypervolemia typically causes hypertension due to increased circulating volume.
E. Flat veins are indicative of hypovolemia, not hypervolemia. In hypervolemia, veins are typically distended due to the excess fluid volume.
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