A nurse is teaching a client who has stage IV pancreatic cancer 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
Choice A rationale
DIC is not controllable with lifelong heparin usage. Heparin may be used to manage DIC, but it is not a permanent solution, and the underlying cause of DIC must be addressed.
Choice B rationale
DIC is caused by abnormal coagulation involving fibrinogen. It is characterized by widespread activation of the clotting cascade, leading to both clot formation and bleeding due to consumption of clotting factors and platelets.
Choice C rationale
DIC is not a genetic disorder involving a vitamin K deficiency. It is an acquired condition resulting from severe illnesses or injuries that trigger abnormal clotting and bleeding processes.
Choice D rationale
DIC is not characterized by an elevated platelet count. Instead, it involves thrombocytopenia due to the consumption of platelets in widespread clotting, leading to a decreased platelet count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Weighing a client with heart failure is a non-invasive and routine task that can be performed by an assistive personnel (AP). Accurate daily weights are essential for monitoring fluid balance in these clients.
Choice B rationale
Incorrect, as providing discharge instructions for a client requires professional nursing judgment and assessment, tasks outside the scope of practice for APs.
Choice C rationale
Incorrect, as performing an admission assessment requires critical thinking and clinical judgment, which are responsibilities of a licensed nurse.
Choice D rationale
Ambulating an older adult client with hypertension can be safely done by an AP. This helps in maintaining the client's mobility and preventing complications such as blood clots and muscle atrophy.
Choice E rationale
Incorrect, as checking a blood product with another nurse prior to administration involves a critical safety check that must be performed by licensed nurses to ensure the right blood is given to the right patient.
Correct Answer is A
Explanation
Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.
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