A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
"DIC is controllable with lifelong heparin usage."
"DIC is caused by abnormal coagulation involving fibrinogen."
"DIC is a genetic disorder involving a vitamin K deficiency."
"DIC is characterized by an elevated platelet count."
The Correct Answer is B
A. "DIC is controllable with lifelong heparin usage": This statement is not accurate. While heparin may be used in the treatment of DIC, it is not a lifelong therapy, and the approach to treatment depends on the underlying cause.
B. "DIC is caused by abnormal coagulation involving fibrinogen": This is the correct answer. DIC is a condition characterized by widespread activation of the clotting cascade, leading to the formation of microthrombi throughout the body. Abnormal coagulation involves the consumption of clotting factors, including fibrinogen.
C. "DIC is a genetic disorder involving a vitamin K deficiency": This statement is not accurate. DIC is not a genetic disorder, and it is not primarily related to vitamin K deficiency. It is an acquired condition often associated with severe infections, sepsis, trauma, or other critical illnesses.
D. "DIC is characterized by an elevated platelet count": This statement is not accurate. In DIC, there is often a decrease in platelet count due to consumption and activation of platelets in the widespread formation of microthrombi.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tissue integrity: While assessing tissue integrity is important, ensuring airway patency takes precedence in the immediate postoperative period, especially following a procedure involving the larynx. Maintaining a patent airway is a critical priority.
B. Pain severity: Pain assessment is important, but it is not the primary concern immediately postoperatively in the context of a partial laryngectomy. Airway patency is of higher priority.
C. Airway patency: This is the correct answer. Following a partial laryngectomy, there may be concerns related to airway compromise due to the surgical procedure. The nurse should assess the airway first to ensure there are no obstructions or complications affecting the client's ability to breathe.
D. Wound drainage: While assessing wound drainage is important for monitoring surgical sites, it is not the first priority in the immediate postoperative period following a partial laryngectomy. Airway patency is a more critical concern.
Correct Answer is A
Explanation
A. Red-colored urine: Rifampin, when taken orally or intravenously, can cause red discoloration of bodily fluids, including urine, sweat, saliva, and tears. This is a common and harmless side effect of the medication. Clients should be informed about this potential discoloration to avoid unnecessary concern.
B. Black-colored stools: Black-colored stools are not an expected side effect of rifampin.
C. Staining of teeth: While rifampin can cause staining of contact lenses, it is not associated with tooth discoloration.
D. Constipation: Constipation is not a common side effect of rifampin. Gastrointestinal side effects may include nausea, vomiting, and abdominal pain.
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