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The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

sudden onset of chest pain and copious sputum

foul smelling concentrated urine

oozing blood from iv sites & previous venipuncture sites

reddened, inflamed central line catheter site

Answer and Explanation

The Correct Answer is C

A. Sudden onset of chest pain and copious sputum

These are more consistent with pulmonary edema or a respiratory infection, not DIC.

B. Foul-smelling concentrated urine

This is suggestive of a urinary tract infection (UTI) or dehydration but is not a hallmark sign of DIC.

C. Oozing blood from IV sites & previous venipuncture sites

DIC is a disorder of excessive clotting and subsequent bleeding. Uncontrolled bleeding from IV sites, surgical wounds, or mucous membranes is a classic sign.

D. Reddened, inflamed central line catheter site

While redness around a catheter site may indicate infection, it is not a defining feature of DIC.

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Correct Answer is C

Explanation

A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.

B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.

C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.

D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.

A. Auscultate bowel sounds, record the findings and obtain a 12-lead ECG B. Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute C. Place soft restraints on the upper extremities and sedate as necessary D. Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Correct Answer is D

Explanation

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

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