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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Bradypnea: Bradypnea refers to abnormally slow breathing. In the context of postoperative atelectasis and hypoxia, the client is more likely to exhibit tachypnea (rapid breathing) as the body attempts to compensate for reduced oxygen levels.

B. Bradycardia: Bradycardia is an abnormally slow heart rate. While hypoxia can lead to changes in heart rate, it is more common to observe tachycardia (increased heart rate) as a compensatory response to decreased oxygen levels.

C. Intercostal retractions: Intercostal retractions occur when the muscles between the ribs pull inward during inspiration. In a client with atelectasis and hypoxia, increased respiratory effort may result in intercostal retractions as the body tries to enhance airflow and improve oxygenation.

D. Lethargy: Lethargy refers to a state of drowsiness or fatigue. While hypoxia can lead to lethargy, it is not a specific respiratory manifestation. Other respiratory signs, such as increased respiratory rate and retractions, are more likely to be observed.

A. Bumetanide 1 mg IV bolus every 12 hr B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain

Correct Answer is C

Explanation

Correct answer: C

A. Bumetanide 1 mg IV bolus every 12 hr is a loop diuretic used to help reduce fluid overload and manage heart failure symptoms. This medication helps remove excess fluid from the body and can be beneficial for a client with acute heart failure following an MI.

B. Laboratory testing of serum potassium upon admission: It is common to monitor serum potassium levels in patients receiving diuretics, especially loop diuretics, to prevent electrolyte imbalances.

C.Administering 0.9% normal saline IV at a continuous rate can potentially exacerbate heart failure by increasing fluid volume, leading to fluid overload and worsening symptoms. In acute heart failure, fluid management is critical, and fluids are typically restricted to prevent further strain on the heart.

D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain: Morphine sulfate is prescribed for pain management and is commonly used in acute heart failure situations to relieve anxiety and decrease preload on the heart. The dosing frequency is appropriate as "every 2 hr PRN" indicates it should be administered as needed for pain relief.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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