A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Excessive thrombosis and bleeding
Increased clotting factors
Progressive increase in platelet production
Immediate sodium and fluid retention
The Correct Answer is A
A. Excessive thrombosis and bleeding
Disseminated Intravascular Coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, leading to both excessive clot formation (thrombosis) and simultaneous consumption of clotting factors and platelets, resulting in bleeding. DIC can occur as a secondary complication to various conditions such as sepsis, trauma, or obstetric complications.
B. Increased clotting factors: In DIC, there is consumption and depletion of clotting factors, not an increase.
C. Progressive increase in platelet production: Platelet production does not increase in DIC; instead, there is consumption and decreased platelet count.
D. Immediate sodium and fluid retention: DIC is not associated with immediate sodium and fluid retention; instead, it is characterized by fluid loss due to bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "This test will help my provider adjust my warfarin dosages": aPTT is not typically used to monitor warfarin therapy. Instead, it is more commonly associated with monitoring heparin therapy.
B. "If my levels are too low, I am at an increased risk for bleeding": This statement is inaccurate. Low levels of clotting factors could lead to a prolonged aPTT, which might increase the risk of bleeding.
C. "It measures deficiencies in clotting factors."
Activated partial thromboplastin time (aPTT) is a laboratory test that evaluates the intrinsic pathway of the coagulation cascade. The aPTT measures the time it takes for a clot to form and reflects the activity of various clotting factors, including factors VIII, IX, XI, and XII. An elevated aPTT may indicate a deficiency or dysfunction of one or more clotting factors.
D. "I will need to skip breakfast until after the test is complete": There is no need for the client to skip breakfast before an aPTT test. The test is not affected by food intake.
Correct Answer is D
Explanation
A. Call emergency services for the client: While difficulty breathing is a concerning symptom, the immediate priority is to assess the client's respiratory status to determine the cause and appropriate interventions. Calling emergency services may be necessary based on the assessment findings, but assessment comes first.
B. Increase the oxygen flow to 3 L/min: Adjusting oxygen flow may be part of the intervention, but it should be based on a comprehensive assessment of the client's respiratory status. Simply increasing the oxygen flow without a thorough assessment may not address the underlying issue.
C. Have the client cough and expectorate secretions: This action may be appropriate if the client is experiencing difficulty breathing due to increased bronchial secretions. However, assessment is needed to determine the cause of the difficulty breathing before implementing interventions.
D. Assess the client's respiratory status: This is the correct answer. Assessment is the priority when a client with COPD on oxygen reports difficulty breathing. The nurse should gather information about the client's respiratory rate, effort, oxygen saturation, lung sounds, and overall respiratory distress to determine the appropriate course of action.
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