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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.
B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.
C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.
D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.
Correct Answer is C
Explanation
A. Urine output of less than 0.5 mL/kg
Norepinephrine is a vasopressor used to improve perfusion. A urine output of less than 0.5 mL/kg suggests ongoing hypoperfusion and inadequate organ perfusion, which is an undesirable outcome.
B. Improved mental status, decreased lactate level
These are positive indicators of improved perfusion and oxygen delivery, but they are not the primary target for norepinephrine therapy.
C. A mean arterial pressure (MAP) of 65
A MAP of at least 65 mmHg is the target for vasopressor therapy, as it ensures adequate perfusion of vital organs.
D. A pain level of 4 or less on a scale of 0-10
While pain management is important, norepinephrine’s primary role is not pain control but rather maintaining adequate perfusion.
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