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 D
Explanation
A. Prepare for immediate surgery to repair the open fracture
Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.
B. Assess for pulses in the upper and lower extremities
Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.
C. Place a sterile pressure dressing on the open fracture
While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.
D. Maintain C-spine immobilization
In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.
Correct Answer is A
Explanation
A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.
B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.
C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.
D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.
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