The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

Hepatomegaly.

Splenomegaly.

Anuria.

Ecchymosis.

Answer and Explanation

The Correct Answer is D

Choice A reason: Hepatomegaly, or enlarged liver, is not a typical finding in DIC. While DIC can affect multiple organs due to widespread microvascular thrombosis and bleeding, hepatomegaly is more commonly associated with other conditions such as liver diseases or congestive heart failure.

Choice B reason: Splenomegaly, or enlarged spleen, is also not a common finding in DIC. Although the spleen can be involved in various hematologic disorders, DIC primarily affects the coagulation and fibrinolytic systems, leading to bleeding and clotting issues rather than spleen enlargement.

Choice C reason: Anuria, or absence of urine production, can occur in severe cases of DIC due to acute kidney injury from microvascular thrombosis or bleeding. However, it is not as common a finding as petechiae, bleeding gums, and ecchymosis. Anuria indicates a critical state requiring immediate intervention but is not the primary expected finding in DIC.

Choice D reason: Ecchymosis, or bruising, is a common finding in DIC. DIC involves widespread activation of the coagulation cascade leading to the consumption of clotting factors and platelets, resulting in bleeding manifestations such as petechiae, bleeding gums, and ecchymosis. These signs indicate the body's inability to form stable clots and the presence of spontaneous bleeding.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["D"]

Explanation

Choice A reason: Administering a vasopressor is not appropriate for low afterload. Vasopressors are used to increase blood pressure by causing vasoconstriction, which increases afterload. However, the administration of a vasopressor for low afterload is contradictory because the goal for low afterload would be to reduce the strain on the heart, not to increase it.

Choice B reason: Administering a vasodilator for low afterload is not correct. Vasodilators decrease afterload by causing the blood vessels to widen, reducing the resistance the heart has to pump against. Administering a vasodilator to treat low afterload is inappropriate because it would further lower afterload, potentially leading to inadequate perfusion and worsening cardiac output.

Choice C reason: Administering diuretics for low right atrial (RA) pressure is inappropriate. Diuretics help to remove excess fluid from the body, reducing blood volume and venous pressure. However, if a patient has low right atrial pressure, reducing blood volume further with diuretics could exacerbate the issue, leading to decreased cardiac output and poor perfusion.

Choice D reason: Administering a fluid bolus is the correct intervention for low preload. Preload refers to the volume of blood in the ventricles at the end of diastole. If preload is low, administering fluids increases blood volume, which enhances ventricular filling and improves cardiac output. This intervention helps to stabilize hemodynamics and improve overall perfusion.

Choice E reason: Administering a diuretic or vasodilator is the appropriate intervention for high preload. High preload indicates an excess of blood volume returning to the heart, which can strain the cardiac muscle and reduce efficiency. Diuretics help remove excess fluid, while vasodilators decrease venous return and reduce the volume of blood the heart has to handle, thus optimizing cardiac function and output.

A. Place the patient on a cardiac monitor immediately. B. Weigh the patient immediately. C. Anticipate a fluid bolus. D. Ask to have the laboratory redraw the blood specimen. E. Anticipate an order for a diuretic. F. Prepare to administer IV insulin and dextrose as ordered. G. Administer Kayexalate (sodium polystyrene) as ordered.

Correct Answer is ["A"]

Explanation

Choice A reason: Placing the patient on a cardiac monitor immediately is crucial due to the elevated potassium level (6.9), which can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and prompt management of any arrhythmias that may occur.

Choice B reason: Weighing the patient immediately is important for assessing fluid status and for calculating appropriate medication dosages. In patients with acute kidney injury, monitoring fluid balance is critical to prevent fluid overload and ensure accurate treatment.

Choice C reason: Anticipating a fluid bolus is not appropriate for this patient. Fluid overload can exacerbate kidney injury and worsen the patient's condition. Fluid management should be carefully tailored based on the patient's overall clinical status and needs.

Choice D reason: Asking to have the laboratory redraw the blood specimen is unnecessary if the initial results are accurate and timely. The focus should be on addressing the critical findings, such as hyperkalemia, rather than retesting.

Choice E reason: Anticipating an order for a diuretic might be considered, but it is not the immediate priority. Diuretics may be useful in managing fluid overload but do not directly address the immediate life-threatening hyperkalemia.

Choice F reason: Preparing to administer IV insulin and dextrose as ordered is essential for treating hyperkalemia. Insulin helps to shift potassium into cells, thereby lowering the serum potassium level. Dextrose is given concurrently to prevent hypoglycemia caused by insulin administration.

Choice G reason: Administering Kayexalate (sodium polystyrene) as ordered is important for removing excess potassium from the body. Kayexalate works by exchanging sodium for potassium in the intestines, promoting the excretion of potassium in the stool.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["D"]

Explanation

A patient is admitted with acute kidney injury and the following assessment cues: K: 6.9 (3.5-5.0) Cr: 3.2 (0.6-1.2) Urine: 300 mL/24 hrs What priority actions should be anticipated by the nurse? Select all that apply.

Correct Answer is ["A"]

Explanation

A 35-year-old patient arrives at the Emergency Department in acute respiratory failure. What assessment information does the nurse prioritize as needing immediate action?

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following cues should the nurse assess to determine if the client is experiencing a myocardial infarction? Pick 2 answers.

The nurse correlates which rationale with the administration of aspirin to the client experiencing angina-like chest pain?

A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?