IV Fluids and Blood Products

Question 1

When we talk about prescribing a patient with fluids there is 1 A and 5 Rs. What does the A stand for?

1 - Add fluids
2 - Assess the patient
3 - Address patients concerns
4 - Add pharmacotherapy

Answer 1

2 - Assess the patient

• this is an assessment of the patients current status

Question 2

When we talk about prescribing a patient with fluids there is 1 A and 5 Rs. What do the 5 Rs stand for?

1 - Routine maintenance, Red flags, Redistribution, Resuscitation, Reassessment
2 - Routine maintenance, Replacement, Redistribution, Red flags, Reassessment
3 - Routine maintenance, Replacement, Reassessment, Resuscitation, Reassessment
4 - Routine maintenance, Replacement, Redistribution, Resuscitation, Reassessment

Answer 2

4 - Routine maintenance, Replacement, Redistribution, Resuscitation, Reassessment

Question 3

Which 2 of the following are physical signs that are important when assessing a patients assessment of fluids?

1 - dry mucous membranes and loss of skin turgor
2 - skin colour membranes and loss of skin turgor
3 - skin colour and loss of skin turgor
4 - mucous membranes and loss of nails

Answer 3

1 - dry mucous membranes and loss of skin turgor

Question 4

NICE has set out guidelines for patients who may require urgent fluid resuscitation. What is the SBP cut off?

1 - <50 mmHg
2 - <75 mmHg
3 - <100 mmHg
4 - <120 mmHg

Answer 4

3 - <100 mmHg

• causing postural hypotension
• can also assess for passive leg raises, where do BP before and during leg raise

Question 5

NICE has set out guidelines for patients who may require urgent fluid resuscitation. What is the pulse rate cut off?

1 - >50bpm
2 - >60bpm
3 - >75bpm
4 - >90bpm

Answer 5

4 - >90bpm

• tachycardia with weak and thready pulse
  HR is fast because less blood so heart hast to work harder to recycle what it has

Question 6

NICE has set out guidelines for patients who may require urgent fluid resuscitation. What is the capillary refill cut off?

1 - <2 seconds
2 - >2 seconds
3 - >5 seconds
4 - >10 seconds

Answer 6

2 - >2 seconds

• cold peripheries is also important
• normal is 2 seconds or less that

Question 7

NICE has set out guidelines for patients who may require urgent fluid resuscitation. What is the respiratory rate cut off?

1 - >15 RR
2 - >20 RR
3 - >25 RR
4 - >30 RR

Answer 7

2 - >20 RR

Question 8

NICE has set out guidelines for patients who may require urgent fluid resuscitation. What is the NEWS cut off?

1 - >2
2 - >4
3 - >5
4 - >7

Answer 8

3 - >5

Question 9

What does a JVP suggest when we are assessing a patients fluid status?

1 - left sided heart failure
2 - pulmonary oedema
3 - postural hypotension
4 - fluid overload

Answer 9

4 - fluid overload
- can also be present in right sided pathophysiology

Question 10

When assessing fluid levels, what is the normal urine output to assess oliguria (low urine output)?

1 - >1ml/hour/kg
2 - >2ml/hour/kg
3 - >4ml/hour/kg
4 - >5ml/hour/kg

Answer 10

4 - >5ml/hour/kg

Question 11

In dehydration the blood can become acidic due to reduced glomerular filtration rate. This means there will be an increase in a specific cation that normally gets filtered and leaves the body as urine. But this can be retained if the eGFR is low, causing metabolic acidosis. Which cation is this?

1 - H+
2 - Ca2+
3 - K+
4 - Na+

Answer 11

1 - H+

Question 12

In dehydration the blood can become too alkaline due the loss of H+ from vomiting and/or diarrhoea. This can lead to metabolic alkalinosis. Which anion level becomes too high causing metabolic alkalinosis?

1 - Cl-
2 - HCO3-
3 - NO3-
4 - S2-

Answer 12

2 - HCO3-

Question 13

In a healthy patient who is coming in for an elective surgery requires and is NBM needs maintenance fluids during the fasting period. Which of the following would be most appropriate maintenance fluids to give to the patient?

1 - 25–30 ml/kg/day of water + 1 mmol/kg/day of potassium & sodium & chloride + 50–100 g/day of glucose to limit starvation ketosis

2 - 25–30 ml/kg/day of water + 1 mmol/kg/day of potassium & sodium & chloride + 100-200 g/day of glucose to limit starvation ketosis

3 - 30-40 ml/kg/day of water + 1 mmol/kg/day of potassium & sodium & chloride + 50–100 g/day of glucose to limit starvation ketosis

25–30 ml/kg/day of water + 10 mmol/kg/day of potassium & sodium & chloride + 50–100 g/day of glucose to limit starvation ketosis

Answer 13

1 - 25–30 ml/kg/day of water + 1 mmol/kg/day of potassium & sodium & chloride + 50–100 g/day of glucose to limit starvation ketosis

• most patients DO NOT need more than 3L/day

Question 14

In a patient who is old/frail, CKD, heart disease, malnourished or at risk of refeeding syndrome we need to adjust their fluid maintenance. What would be the recommended fluid intake?

1 - 25–30 ml/kg/day of water
2 - 25–40 ml/kg/day of water
3 - 20–25 ml/kg/day of water
4 - 15–20 ml/kg/day of water

Answer 14

3 - 20–25 ml/kg/day of water

• too much fluid puts the patient at risk of fluid overload

Question 15

If a patient requires resuscitation, which of the following would they be given?

1 - colloids with Na+ 130–154 mmol/l
2 - colloids with K+ 130–154 mmol/l
3 - crystalloids with Na+ 130–154 mmol/l
4 - crystalloids with K+ 130–154 mmol/l

Answer 15

3 - crystalloids with Na+ 130–154 mmol/l

• nor glucose, starch or gelatine products given

Question 16

If a patient requires resuscitation, which rate should a bolus be given?

1 - 250ml <30 minutes
2 - 250ml <15 minutes
3 - 500ml <15 minutes
4 - 1L <15 minutes

Answer 16

3 - 500ml <15 minutes

• if patient is frail it should be 250ml <15 minutes

Question 17

If we were to give a patient just 0.9% saline, which contains 154mmol/L of Na+ and Cl-, what would this eventually do to the patient?

1 - hypernatremic, hyperchloremia and metabolic acidosis
2 - pulmonary oedema
3 - cause alkalosis
4 - renal failure

Answer 17

1 - can become hypernatremic, hyperchloremia and metabolic acidosis follows

• pH of normal saline is 3.5-6.5

Question 18

Normal saline is a fluid given to patients when they need to increase their fluid levels. It is 0.9% saline including Na+ and Cl- both at 154mmol/L. If a patient is given too much of the normal saline alone they can develop hypernatremic and metabolic acidosis follows. To stop this from happening patients are given 2L of normal saline with 1L of 5% glucose. Why is the glucose given alongside?

1 - glucose neutralises Na+ and Cl-
2 - glucose provides calories
3 - glucose provides calories and is metabolised into H2O
4 - glucose is metabolised into H2O

Answer 18

3 - glucose provides calories and is metabolised into H2O

• the H2O neutralises the acidity of the normal saline

Question 19

33-year-old man presents to the emergency department with a 3 day history of melaena. PMH. Recent cruciate ligament surgery. DH. Ibuprofen 400 mg PO 8-hrly for the past week.

On Examination:
He is speaking in full sentences; Oxygen Sats 96% on room air
Temperature 36.4°C; HR 132/min and rhythm regular; BP 82/50 mmHg.
PR = Melaena.

The patient is being assessed. What is the next step in the fluid management process?

1 - fluid in the knee following surgery
2 - vomiting and diarrhoea following surgery
3 - fluid loss through the bowels
4 - lack of fluid intake

Answer 19

3 - fluid loss through the bowels

• Ibuprofen 400 mg can cause an ulcer, evidenced by the melaena
• blood is very osmotically active so it sucks more fluid into the bowels

Question 20

If we are providing a patient with maintenance fluids, we need to be sure that the patient is not inappropriately redistributing them elsewhere. Which of the following can cause a redistribution imbalance or due to significant comorbidity?

1 - gross oedema
2 - severe sepsis (loss of tight junctions in endothelium resulting in loss of fluid in extravascular space)
3 - hyponatraemia or hypernatraemia (affects on semi-permeable membranes)
4 - renal, liver and/or cardiac impairment
5 - post-operative fluid retention and redistribution
6 - malnourished and refeeding issues
7 - all of the above

Answer 20

7 - all of the above

• need to re-assess with fluids, as fluid may be lost, so giving more is pointless until you address the issue

Question 21

33-year-old man presents to the emergency department with a 3 day history of melaena. PMH. Recent cruciate ligament surgery. DH. Ibuprofen 400 mg PO 8-hrly for the past week.

On Examination:
He is speaking in full sentences; Oxygen Sats 96% on room air
Temperature 36.4°C; HR 132/min and rhythm regular; BP 82/50 mmHg.
PR = Melaena.

The most likely cause of the fluid loss causing a BP of 82/50 mmHg and a HR of 132bpm is fluid in the stomach due to ibuprofen evidenced by melaena. What fluid should be provided?

1 - 250ml <30 minutes
2 - 250ml <15 minutes
3 - 500ml <15 minutes
4 - 1L <15 minutes

Answer 21

3 - 500ml <15 minutes

• Hartmans solution

Question 22

A 65-year-old man presents to the emergency department because he is feeling weak and unwell. He has had diarrhoea and vomiting for the past 2 days following a takeaway meal.

On Examination:
He is speaking in full sentences; Oxygen Sats 96% on room air
Temperature 37.1°C, HR 102/min and rhythm regular, BP 102/60 mmHg. Weight 70 kg.

Investigations:
Na+ 126 mmol/L (137–144), K+ 2.4 mmol/L (3.5–5.3), U 12.0 mmol/L (2.5–7.0), Cr 97 µmol/L (60–110).

What is the likely cause of the fluid loss causing a BP of 102/60 mmHg and a HR of 102bpm?

1 - increased fluid out of urine due to low osmolality
2 - vomiting and diarrhoea following takeaway
3 - fluid loss through the bowels
4 - lack of fluid intake

Answer 22

2 - vomiting and diarrhoea following takeaway

Question 23

A 65-year-old man presents to the emergency department because he is feeling weak and unwell. He has had diarrhoea and vomiting for the past 2 days following a takeaway meal.

On Examination:
He is speaking in full sentences; Oxygen Sats 96% on room air
Temperature 37.1°C, HR 102/min and rhythm regular, BP 102/60 mmHg. Weight 70 kg.

Investigations:
Na+ 126 mmol/L (137–144), K+ 2.4 mmol/L (3.5–5.3), U 12.0 mmol/L (2.5–7.0), Cr 97 µmol/L (60–110).

What fluid should be provided?

1 - 250ml <30 minutes
2 - 250ml <15 minutes
3 - 500ml <15 minutes
4 - 1L <15 minutes

Answer 23

3 - 500ml <15 minutes

• Hartmans solution

Question 24

Patients who are dehydrated can have a high urea in their urine, which is a breakdown product from protein metabolism in the liver. Why can dehydration cause increased urea?

1 - increase eGFR
2 - decreased eGFR
3 - decreased eGFR and high anti-diuretic hormone
4 - high ADH levels

Answer 24

3 - decreased eGFR and high anti-diuretic hormone

• kidneys are not filtering properly
• ADH retains fluid and urea is retained as well

Question 25

A 77-year-old woman presents to the emergency department with a history of right sided weakness which she noticed on waking. She also has slurred speech and a weak swallow. PMH. Hypertension. DH. Amlodipine; Ramipril

Further assessments are being performed and she is nil by mouth.
Weight = 60 kg

What are appropriate IV maintenance fluids

1 - 600m/day
2 - 900ml/day
3 - 1200ml/day
4 - 2000ml/day

Answer 25

3 - 1200ml/day

• recommendation for elderly/ill is 20–25 ml/kg/day fluid
• patient is 60kg
  60 x 20 = 1200
  60 x 25 = 1500

Question 26

A 55-year-old woman presents to the emergency department with a history of recurrent palpitations. She was started on a new tablet 6 weeks ago. PMH. Resistant Hypertension. Coronary Artery Disease DH. Amlodipine; Ramipril; Indapamide; Bisoprolol; Aspirin; Atorvastatin; Spironolactone.

Examination - Unremarkable

Investigations - Na+ 136 mmol/L (137–144), K+ 6.8 mmol/L (3.5–5.3), U 7.2 mmol/L (2.5–7.0), Cr 70 µmol/L (60–110).
ECG = Broad QRS complexes
She has been put on a cardiac monitor.

In this scenario what fluid should be given in maintenance?

1 - 250ml <15 minutes Hartmans solution
2 - 500ml <15 minutes Hartmans solution
3 - 250ml <15 minutes normal saline solution
4 - 500ml <15 minutes normal saline solution

Answer 26

3 - 250ml <15 minutes normal saline solution

• she has high K+ so do not want to give more

Question 27

A 55-year-old woman presents to the emergency department with a history of recurrent palpitations. She was started on a new tablet 6 weeks ago. PMH. Resistant Hypertension. Coronary Artery Disease DH. Amlodipine; Ramipril; Indapamide; Bisoprolol; Aspirin; Atorvastatin; Spironolactone.

Examination - Unremarkable

Investigations - Na+ 136 mmol/L (137–144), K+ 6.8 mmol/L (3.5–5.3), U 7.2 mmol/L (2.5–7.0), Cr 70 µmol/L (60–110).
ECG = Broad QRS complexes
She has been put on a cardiac monitor

Here the patient may be given some normal saline, but also needs to be given something else. What would that be?

1 - Na+ and Ca2+ gluconate
2 - Cl- and Ca2+ gluconate
3 - Ca2+ gluconate
4 - Na+ and glucose

Answer 27

3 - Ca2+ gluconate

• medication to manage hypocalcemia, cardiac arrest, and cardiotoxicity due to hyperkalemia or hypermagnesemia.

Question 28

Which of the following is NOT an alternative to a blood transfusion?

1 - Erythropoietin
2 - Intravenous and oral iron
3 - Tranexamic acid (reduces bleeding)
4 - Folic acid

Answer 28

4 - Folic acid

Question 29

Which 2 of the following are the most common variables used as a blood transfusion trigger?

1 - WBC
2 - platelets
3 - Haemoglobin
4 - Haematocrit

Answer 29

3 - Haemoglobin
4 - Haematocrit
- proportion of RBCs in the blood

Question 30

If a patient presented with a haemoglobin of 68g/L, which of the following would you give him?

1 - 1 unit of whole blood
2 - 1 unit of RBCs
3 - 1 unit of platelets
4 - 1 unit of WBC

Answer 30

2 - 1 unit of RBCs

• PRBCs = packed RBCs
• this is what is used in trust

Question 31

If it is not a trauma situation, how quickly should RBCs be transfused?

1 - <60 minutes
2 - <120 minutes
3 - 60-120 minutes
4 - 60-240 minutes

Answer 31

3 - 60-120 minutes

• no slower than over 4 hours because they are an infection risk if they become warm

Question 32

If it is not a trauma situation, how quickly should platelets be transfused?

1 - <30 minutes
2 - 30-60 minutes
3 - 60-120 minutes
4 - >120 minutes

Answer 32

2 - 30-60 minutes

Question 33

If it is not a trauma situation, how quickly should fresh frozen plasma be transfused?

1 - 10-20ml/kg/hour
2 - 20ml/kg/hour
3 - 10ml/kg/hour
4 - 30-40ml/kg/hour

Answer 33

1 - 10–20 mL/kg/hour

Question 34

Patients can present with a broad array of symptoms, which are suggestive of a transfusion reaction. Which of the following are commonly seen?

1 - Fever, chills, rigors
2 - Hyper- / Hypo-tension
3 - Collapse
4 - Flushing
5 - Urticaria (hives on skin)
6 - Pain (bone, muscle, chest, abdominal)
7 - Respiratory distress
8 - Nausea
9 - General malaise
10 - all of the above

Answer 34

10 - all of the above

Question 35

If a patient has a reaction to a blood transfusion, which of the following is NOT done immediately?

1 - STOP transfusion, but do not detach
2 - complete observations
3 - change transfusion
4 - check identify of patient

Answer 35

3 - change transfusion

• need to do lots of checks before transfusing again

if any of the checks above are incorrect then disconnect the blood

Question 36

If a patient has a reaction to a blood transfusion, the transfusion should be stopped, but not detached, complete observations. Which of the following must also be done relating to the transfusion?

1 - check patient ID (patient wristband)
2 - check unit of blood is correct (tag on blood bag)
3 - check labels on blood (label on bag)
4 - all of the above

Answer 36

4 - all of the above