NORCET 5 Prelims - Sept 2023 (Shift-2)
Medical & Surgical Nursing
Medium
A Patient comes in emergency with the femur fracture and severe hemorrhage then which fluid should not give?
Appeared in: NORCET 5 Prelims - Sept 2023 (Shift-2)
Explanation
- 45% NS is a hypotonic solution, meaning it has a lower solute concentration than the body's cells and blood plasma.
- When administered to a patient with hemorrhage, a hypotonic solution causes a fluid shift from the intravascular space into the interstitial and intracellular spaces due to osmosis.
- This movement of fluid out of the blood vessels further depletes the circulating volume, worsening hypotension, shock, and potentially causing life-threatening cellular edema, especially in the brain.
Why Other Options Were Wrong
- Option A: Ringer's Lactate (RL) is an isotonic crystalloid solution. It is a first-line choice for fluid resuscitation in trauma and hemorrhage because it rapidly expands intravascular volume.
- Option B: 9% Normal Saline (NS) is an isotonic crystalloid solution. Like RL, it is a standard and appropriate choice for replacing volume in patients with hemorrhagic shock.
- Option D: Colloids (e.g., albumin, dextran) are volume expanders. They contain large molecules that remain in the vascular space, increasing oncotic pressure and pulling fluid in. They are a valid, though often second-line, option for resuscitation in hemorrhagic shock.
Related Visual
Clinical Relevance
- Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing IV fluid management in hypovolemic shock in acute care settings.
- In an emergency, selecting the correct IV fluid is a critical nursing responsibility that directly impacts patient survival. Using a hypotonic solution in a bleeding patient can rapidly lead to cardiovascular collapse.
- Nurses must be able to quickly assess for signs of hypovolemic shock (e.g., tachycardia, hypotension, pallor, cool extremities, delayed capillary refill) and anticipate the need for rapid infusion of isotonic crystalloids.
- What if the patient had severe cellular dehydration due to hypernatremia (high sodium) without shock? In that specific case, a hypotonic solution like 0.45% NS would be the appropriate choice to slowly rehydrate the cells and correct the sodium imbalance.
How to Approach the Question
- First, identify the patient's primary clinical problem from the stem. 'Femur fracture' and 'severe hemorrhage' point directly to hypovolemic shock from blood loss.
- Next, determine the immediate therapeutic goal. For hypovolemic shock, the goal is to rapidly increase the fluid volume within the blood vessels (intravascular space).
- Recognize the negative framing of the question: 'which fluid should not give?'. This means you are looking for the option that is contraindicated or harmful.
- Evaluate each fluid option based on its tonicity and its effect on fluid distribution in the body.
- Recall that isotonic fluids (RL, 0.9% NS) stay in the vascular space and are ideal for resuscitation.
- Recall that hypotonic fluids (0.45% NS) cause fluid to leave the vascular space, which would worsen shock.
Concept Tested & Keywords
- Concept Tested: IV fluid management in hypovolemic shock
- Stem keywords: femur fracture, severe hemorrhage, emergency, fluid
- Lead-in keywords: should not give
- Clinical cues: The combination of 'femur fracture' and 'severe hemorrhage' is a classic presentation for hypovolemic shock, guiding the choice of resuscitation fluid.
- Negative lead-in flag: The question asks to identify the contraindicated fluid, requiring an understanding of which option would be harmful.
Question ID
QEeGwxRRS5DrTA4gT0hbXk
Reference Book
E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 142-144
E6 Pharmacology Nursing Lilley 11e Part 2 p. 161-163
E6 Gynecology Williams p. 7-26
Practise the full NORCET 5 Prelims - Sept 2023 (Shift-2)
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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