Okay let's look at the question. "The nurse cares for a client in ER who is admitted with abdominal
trauma following a motor vehicle accident." Okay, so what's particular about this patient? My
setting is ER. They had an abdominal trauma after a motor vehicle accident. Okay, worst case
scenario? Whoah, if they took a hit to the gut I'm worried about bleeding. The client's vital
signs are heart rate 126, that's high; blood pressure 90/58, that's low; respirations 24, yeah
I'm not that impressed with that, it's okay; and temperature 98.9. Okay, but what concerns me
is I'm in ER for an abdominal trauma. My biggest concern from that would be bleeding and I know
they've had a motor vehicle accident. Now their heart rate is fast, their blood pressure is low.
Yeah, those red flags are going up for me. So which of the following orders would be most important
for the nurse to question? Well, I'm going to question anything that's going to put this particular
patient, trauma from abdominal, worried about bleeding with vital signs that are pulse too high,
blood pressure too low so they're showing me signs that it could be bleeding. So in this particular
patient, this particular setting, what would keep them the safest? Oh, but wait a minute look
at that line again. Which of the following orders would be most important for the nurse to question?
Uhhhh, that question is asking me which of these orders would be unsafe for this patient? Okay,
so I'm going to give 4 options for 0.45% normal saline at 100 mL/hour, normal saline at 150 mL/hour,
Lactated Ringer's at 75 mL/hour, 1 unit packed red blood cells. What I want you to do is to walk to
this question and eliminate 3 answers but make yourself say why. Now here's what I would do
if I were you. I would go through each one of these IVs or these fluids and I would say "Is it
hypotonic, isotonic, or hypertonic?" And then I would make a note to myself "Which way do I think
that would cause fluid to shift?" So work your way through this question and then I'll come back and
tell you the correct answer but don't take a shortcut. Make yourself with every solution, identified
as iso, hypo, or hypertonic and ask yourself which way fluid would shift. Would it shift into the
cell or out of the cell and what impact would it have on this patient. Okay, let's look at the
answer choices. Now this patient's blood pressure is already low, heart rate is too high. I know
for a fact I'm really concerned about them staying stable. Right? So, the worst possible IV fluid
IV fluid I could give them if I think through, isotonic shouldn't cause to shift, hypertonic will
cause fluid to shift out of the cells into the intravascular space, hypotonic will take fluid from
the intravascular space and shove it into the cells. That's the one I'm going to follow up on.
Blood should not cause fluid volume to shift very much. Lactated Ringer's, normal saline. Did
you identify what type of those solutions those were? See, that's not going to give us a problem but
the 0.45% normal saline, that's the order I'm going to question because I want to keep this patient
safe. It's a hypotonic solution. So that will cause fluid to shift from the intravascular space into
the cells, meaning that blood pressure will drop even further. So that's why the correct answer
is a most important for me to follow up on a. Okay, let's try another question. You did really
well on that one, let's see how you're doing on this one. Without looking at your notes, I want
you to name the 3 types of IV solution. Hint, think tonicity. Now I want you to name 2 IV fluids
that cause fluid volume to shift from the cells into the vascular system. See if you can actually
remember the names of the individual fluids, not just their tonicity but the names of the fluids.
Now here's a good one. First of all I want you to pick the IV solutions. This will be a good test
live for you to think through what we just talked about but the name of the IV solution on the
left, then think what type of patients it would be good for (that's the checkbox) and think of
the X (patients that should not receive that type of solution). Work your way back to the
presentation just to make sure you have each one of those patterns selling in your mind.