A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
The laboratory values are within the expected reference range.
The laboratory values are prolonged.
The laboratory values are the same as the previous test values.
The laboratory values are decreased.
The Correct Answer is B
Choice A Reason: This is incorrect because the laboratory values are not within the expected reference range in a client who has DIC. DIC is a condition that causes abnormal activation of the clotting cascade, leading to widespread microthrombi formation and consumption of clotting factors and platelets. This results in bleeding complications and organ dysfunction.
Choice B Reason: This is correct because the laboratory values are prolonged in a client who has DIC. PT, aPTT, and INR are tests that measure the time it takes for blood to clot. PT measures the extrinsic pathway, aPTT measures the intrinsic pathway, and INR is a standardized ratio of PT. In DIC, these tests are prolonged because of the depletion of clotting factors and platelets.
Choice C Reason: This is incorrect because the laboratory values are not the same as the previous test values in a client who has DIC. DIC is an acute and dynamic condition that can change rapidly depending on the underlying cause and treatment. The laboratory values may fluctuate between normal, prolonged, or shortened depending on the balance between clotting and bleeding.
Choice D Reason: This is incorrect because the laboratory values are not decreased in a client who has DIC. Decreased laboratory values would indicate a shortened clotting time, which can occur in some cases of DIC when there is excessive clotting and thrombosis. However, this is not the typical finding in DIC, as most clients present with bleeding manifestations and prolonged clotting time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because hypervolemia is a condition of excess fluid volume in the body. A client who has an extensive burn injury is more likely to have hypovolemia, which is a condition of low fluid volume, due to fluid loss from the damaged skin and capillaries.
Choice B Reason: This is incorrect because metabolic alkalosis is a condition of high blood pH and high bicarbonate level. A client who has an extensive burn injury is more likely to have metabolic acidosis, which is a condition of low blood pH and low bicarbonate level, due to increased production of lactic acid and ketones from tissue hypoxia and breakdown.
Choice C Reason: This is correct because low hemoglobin is a common laboratory finding in a client who has an extensive burn injury. Hemoglobin is the protein in red blood cells that carries oxygen. A client who has an extensive burn injury may have low hemoglobin due to hemolysis, which is the destruction of red blood cells, or hemorrhage, which is the loss of blood.
Choice D Reason: This is incorrect because hyperkalemia is a condition of high blood potassium level. A client who has an extensive burn injury may have hyperkalemia in the early phase of injury, due to cell damage and potassium release, but it is usually transient and followed by hypokalemia, which is a condition of low blood potassium level, due to fluid loss and potassium depletion.
Correct Answer is B
Explanation
Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood flow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).
Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal fluid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.
Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inflammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.
Choice D Reason: This choice is incorrect because decreasing the oxygen flow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.
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