A nurse is assisting with the care of a client who has septic shock and is at risk for disseminated intravascular coagulation (DIC). Which of the following nursing statements indicates an understanding of the condition?
DIC is a genetic disorder involving vitamin K deficiency.
DIC is characterized by an elevated platelet count.
DIC is controllable with lifelong heparin usage.
DIC is caused by abnormal coagulation involving fibrinogen.
The Correct Answer is D
A. DIC is not a genetic disorder but is often secondary to other conditions.
B. In DIC, platelet count decreases rather than increases.
C. While heparin may be used in the treatment of DIC, it is not a lifelong therapy, and its use depends on the specific clinical situation.
D. DIC involves abnormal coagulation, with consumption of clotting factors and fibrinogen, leading to both bleeding and thrombosis.
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Related Questions
Correct Answer is B
Explanation
A. Leaving the client during a seizure can lead to injury. The nurse should stay with the client.
B. Placing a towel under the client's head helps protect the head from injury during a seizure.
C. Placing the client in the prone position can compromise the airway and increase the risk of aspiration.
D. Holding the client's arms and legs still can be difficult and may result in injury to the client or the nurse. The priority is to protect the client from injury during the seizure.
Correct Answer is D
Explanation
A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.
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