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 D
Explanation
This question requires knowledge of acid-base balance and pathophysiology of chronic kidney disease. Understanding how impaired renal function leads to metabolic acidosis through decreased hydrogen ion excretion and reduced bicarbonate regeneration is essential to identify the correct values.
Choice A rationale
A pH of 7.55 and HCO3 of 30 indicate metabolic alkalosis. Normal pH is 7.35 to 7.45 and HCO3 is 22 to 28 mEq/L. Renal failure typically results in acid accumulation, not excess base.
Choice B rationale
A pH of 7.30 and PaCO2 of 50 indicate respiratory acidosis. In renal failure, the lungs typically compensate for metabolic acid by hyperventilating to lower PaCO2, which is the opposite of the hypoventilation shown here.
Choice C rationale
A pH of 7.50 and PaCO2 of 32 indicate respiratory alkalosis. This state occurs when the patient hyperventilates excessively, leading to an alkaline pH, which does not align with the metabolic acidosis expected in renal disease.
Choice D rationale
Chronic kidney disease causes metabolic acidosis. A pH of 7.25 and HCO3 of 19 mEq/L demonstrate low pH and low bicarbonate. The PaCO2 of 30 mm Hg reflects respiratory compensation for the primary metabolic acid-base imbalance.
Correct Answer is A
Explanation
This clinical scenario focuses on postoperative care for split-thickness skin grafts and integumentary rehabilitation. Knowledge of tissue fragility, ultraviolet radiation sensitivity, and wound healing phases is required to prevent graft failure, hyperpigmentation, and secondary injury during the remodeling phase.
Choice A rationale
Newly grafted skin lacks melanocytes and the protective epidermal barrier, making it highly susceptible to ultraviolet damage. Direct sunlight can cause severe sunburn and permanent hyperpigmentation. Protection ensures long-term graft viability and prevents tissue degradation.
Choice B rationale
Physical therapy is vital to prevent contractures and maintain range of motion in burned limbs. While necessary for functional recovery, it is not the immediate priority over preventing physical damage to the fragile graft site from environmental factors.
Choice C rationale
Cosmetic camouflage helps manage the psychological impact of scarring and skin discoloration. While important for holistic recovery and body image, it is a psychosocial intervention that ranks lower than physiological protection of the surgical graft site.
Choice D rationale
Burn recovery requires a high-protein, high-calorie diet to support tissue synthesis and positive nitrogen balance. A low-protein diet would be contraindicated as it impairs collagen formation and delays wound healing in recovering burn patients.
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