Á 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. Lifelong heparin usage is not the standard treatment for DIC, as treatment focuses on addressing the underlying cause and managing symptoms.
B. DIC is a condition characterized by abnormal, excessive coagulation involving the use of clotting factors, particularly fibrinogen, leading to widespread clotting and bleeding.
C. DIC is not a genetic disorder or directly related to vitamin K deficiency.
D. DIC typically leads to a decreased platelet count due to consumption of platelets in widespread clotting, not an elevated count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.
B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.
C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.
D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.
E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.
F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.
Correct Answer is D
Explanation
A. A protective environment is not necessary; Clostridium difficile requires contact precautions.
B. Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores; handwashing with soap and water is essential.
C. Wearing a mask is not necessary as C. difficile is transmitted through spores that survive on surfaces.
D. Disinfecting equipment daily helps reduce the risk of C. difficile spore transmission within the environment.
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