The nurse assesses a client with disseminated intravascular coagulation who is being treated with blood products and heparin.
Which cues indicate worsening organ dysfunction and continued bleeding? Select all that apply.
Prolonged prothrombin time (PT).
Elevated D-dimer levels.
Increased capillary refill > 5 seconds.
Presence of petechiae and purpura on the skin.
Decreased urine output.
Normal platelet count.
Correct Answer : C,E
Managing disseminated intravascular coagulation involves identifying secondary complications of microvascular thrombosis and hemorrhage. Knowledge of coagulation pathways and end-organ perfusion assessment is required to differentiate between laboratory markers of the disease process and clinical indicators of worsening organ failure.
Choice A rationale
A prolonged prothrombin time, where the normal range is 11 to 13.5 seconds, is a diagnostic laboratory finding for this condition. However, it represents a hematological marker of the clotting cascade exhaustion rather than organ dysfunction.
Choice B rationale
Elevated D-dimer, with a normal range usually less than 500 ng/mL, indicates active fibrinolysis. While it confirms the presence of the disorder and ongoing clot breakdown, it is a laboratory value, not a clinical cue.
Choice C rationale
Capillary refill greater than 3 seconds indicates poor peripheral tissue perfusion. In this condition, microthrombi obstruct small vessels, leading to ischemia. A refill of 5 seconds signals significant circulatory compromise and potential progression toward multi-organ failure.
Choice D rationale
Petechiae and purpura are classic integumentary signs of bleeding due to thrombocytopenia and clotting factor depletion. While they signify active bleeding, they are considered standard symptoms of the disease rather than specific markers of organ dysfunction.
Choice E rationale
Decreased urine output, typically defined as less than 30 mL per hour, indicates impaired renal perfusion or acute kidney injury. This occurs due to microvascular thrombi in the renal capillaries, signaling significant organ dysfunction.
Choice F rationale
A normal platelet count, ranging from 150,000 to 450,000 cells/mm, would indicate improvement rather than worsening. In active cases, platelets are rapidly consumed, leading to severe thrombocytopenia as the body attempts to form micro-clots throughout the vasculature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This scenario focuses on acute fluid resuscitation following thermal injury. Knowledge of fluid shift dynamics during the emergent phase of burns is essential to prevent hypovolemic shock. Crystalloid selection must prioritize electrolyte balance and volume expansion to maintain organ perfusion.
Choice A rationale
Albumin is a colloid used for volume expansion but is generally avoided in the first 24 hours of burn care. Increased capillary permeability allows large molecules to leak into interstitium, worsening edema rather than maintaining intravascular volume.
Choice B rationale
This isotonic crystalloid is the gold standard for burn resuscitation. It closely mimics extracellular fluid and provides essential electrolytes. The lactate is metabolized into bicarbonate, which helps buffer the metabolic acidosis commonly seen in major thermal injuries.
Choice C rationale
Dextrose in water is a hypotonic solution once glucose is metabolized. It does not stay in the intravascular space and can lead to cellular edema. It is ineffective for volume resuscitation and may cause dangerous electrolyte imbalances.
Choice D rationale
While normal saline is isotonic, adding potassium is contraindicated in the emergent burn phase. Damaged cells release intracellular potassium into the bloodstream, making hyperkalemia a significant risk. Normal range for potassium is 3.5 to 5.0 mEq/L.
Correct Answer is B
Explanation
Disseminated intravascular coagulation involves systemic activation of coagulation, leading to microthrombi formation. Assessing for organ dysfunction requires understanding how thrombotic microangiopathy causes ischemia in high-vascularity organs, specifically focusing on renal and hepatic biomarkers and physiological changes in perfusion.
Choice A rationale
Thrombotic microangiopathy in the lungs would typically cause increased respiratory rates and decreased oxygen saturation due to impaired gas exchange. Decreased rates and normal saturation do not indicate the ischemic damage associated with microvascular clotting.
Choice B rationale
The kidneys are highly susceptible to microthrombi. Elevated BUN (normal 10 to 20 mg/dL) and creatinine (normal 0.6 to 1.2 mg/dL) indicate acute kidney injury caused by fibrin deposition and subsequent ischemia in the glomerular capillaries.
Choice C rationale
While bilirubin might rise due to hemolysis, white blood cell counts are not a primary indicator of thrombotic organ dysfunction. Bilirubin increases are more common in hepatic failure or red blood cell fragmentation during DIC.
Choice D rationale
DIC typically presents with abnormal coagulation profiles, including prolonged PT and PTT and low fibrinogen. Normal profiles would contradict the diagnosis of DIC, even if transaminases were elevated due to localized hepatic microvascular occlusion.
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