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.

Answer and Explanation

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.

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Correct Answer is ["100"]

Explanation

To estimate the percentage of body surface area burned using the Rule of Nines, follow these guidelines:

Head and Neck: 9%
Each Arm: 9% (right arm) + 9% (left arm) = 18%
Front of Torso: 18%
Back of Torso: 18%
Each Leg: 18% (right leg) + 18% (left leg) = 36%
Genital Area: 1%

Now, add up the percentages of the burned areas:

9% (head and neck) + 18% (each arm) + 18% (front of torso) + 18% (back of torso) + 36% (each leg) + 1% (genital area) = 100%

So, the nurse should estimate that the client has burned 100% of their body surface area.

A. Observe for cerebrospinal ﬂuid (CSF) leaks from the evacuation site. B. Check the oximeter. C. Assess for an increase in temperature. D. Monitor for manifestations of increased intracranial pressure.

Correct Answer is B

Explanation

Choice A Reason: Observing for cerebrospinal ﬂuid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice B Reason: The first action the nurse should take when caring for a client post-evacuation of a subdural hematoma is to check the oximeter to ensure adequate oxygenation. Maintaining proper oxygenation is a priority because hypoxia and hypercapnia can lead to cerebral vasodilation, increasing intracranial pressure (ICP) and worsening neurological outcomes.Key Concept: Always prioritize Airway, Breathing, and Circulation (ABCs) when determining the most immediate nursing intervention.

Choice C Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inﬂammation, or damage to the hypothalamus, which can aﬀect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice D Reason:This is crucial, but oxygenation status should be checked first since low oxygen levels can worsen ICP.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV ﬂuid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate ﬂuid replacement?

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

A nurse is monitoring the ﬂuid replacement of a client who has sustained burns. The nurse should administer which of the following ﬂuids in the first 24 hr following a burn injury?

A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?