The nurse reviews laboratory results for a client with disseminated intravascular coagulation who is being monitored for complications related to abnormal clotting.
Which findings would most suggest the development of organ dysfunction secondary to thrombotic microangiopathy?
Decreased respiratory rate and normal oxygen saturation.
Elevated blood urea nitrogen (BUN) and serum creatinine.
Decreased white blood cell count and increased bilirubin.
Elevated liver transaminases and normal coagulation profiles.
The Correct Answer is B
Disseminated intravascular coagulation involves systemic activation of coagulation, leading to microthrombi formation. Assessing for organ dysfunction requires understanding how thrombotic microangiopathy causes ischemia in high-vascularity organs, specifically focusing on renal and hepatic biomarkers and physiological changes in perfusion.
Choice A rationale
Thrombotic microangiopathy in the lungs would typically cause increased respiratory rates and decreased oxygen saturation due to impaired gas exchange. Decreased rates and normal saturation do not indicate the ischemic damage associated with microvascular clotting.
Choice B rationale
The kidneys are highly susceptible to microthrombi. Elevated BUN (normal 10 to 20 mg/dL) and creatinine (normal 0.6 to 1.2 mg/dL) indicate acute kidney injury caused by fibrin deposition and subsequent ischemia in the glomerular capillaries.
Choice C rationale
While bilirubin might rise due to hemolysis, white blood cell counts are not a primary indicator of thrombotic organ dysfunction. Bilirubin increases are more common in hepatic failure or red blood cell fragmentation during DIC.
Choice D rationale
DIC typically presents with abnormal coagulation profiles, including prolonged PT and PTT and low fibrinogen. Normal profiles would contradict the diagnosis of DIC, even if transaminases were elevated due to localized hepatic microvascular occlusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Chest tube management for pneumothorax involves monitoring for clinical complications and system patency. This scenario requires applying knowledge of respiratory emergencies, specifically recognizing signs of tension pneumothorax, which is a life threatening complication characterized by shifting of thoracic structures.
Choice A rationale
Tracheal deviation toward the unaffected side signifies a tension pneumothorax. This occurs when intrapleural pressure increases significantly, causing a mediastinal shift that compresses the heart and opposite lung, requiring immediate needle decompression or chest tube adjustment by providers.
Choice B rationale
Eyelets are the drainage holes at the end of the chest tube. If they are not visible, it indicates the tube is correctly positioned within the pleural space. Visible eyelets would suggest the tube has partially dislodged.
Choice C rationale
Crepitus, or subcutaneous emphysema, is a common finding where air leaks into subcutaneous tissues around the insertion site. While it should be monitored and documented, it generally does not require emergency provider notification unless it rapidly expands.
Choice D rationale
Intermittent bubbling in the water seal chamber during exhalation or coughing is expected in a patient with a pneumothorax. It indicates that air is successfully being evacuated from the pleural space into the drainage system.
Correct Answer is ["B","C","D"]
Explanation
Managing hyperkalemia and burn injuries necessitates rapid assessment and specialized intervention. Understanding the electrophysiology of the heart and the mechanical pressure exerted by burned skin allows nurses to intervene effectively to stabilize cardiac rhythms and maintain peripheral pulses and perfusion.
Choice A rationale
Potassium supplements would exacerbate hyperkalemia, further increasing the extracellular potassium concentration. This would worsen cardiac membrane depolarization, potentially leading to fatal ventricular arrhythmias or asystole. Normal serum potassium levels range from 3.5 to 5.0 mEq/L.
Choice B rationale
Continuous cardiac monitoring is vital because hyperkalemia alters the myocardial resting membrane potential. This can lead to peaked T waves, widened QRS complexes, and cardiac arrest. Constant surveillance allows for immediate detection of life-threatening electrical changes.
Choice C rationale
Calcium gluconate is administered to stabilize the cardiac cell membrane. It does not lower potassium levels but antagonizes the cardiotoxic effects of hyperkalemia by increasing the threshold potential, thereby reducing the risk of lethal arrhythmias.
Choice D rationale
Hemodialysis is the most definitive and rapid method to remove excess potassium from the blood. It is indicated in severe, symptomatic hyperkalemia when medical therapies are insufficient to stabilize the patient or clear the electrolyte.
Choice E rationale
While diuretics like furosemide can increase potassium excretion, they are often too slow for emergency stabilization in severe hyperkalemia with arrhythmias. They require adequate renal perfusion and function, making them a secondary rather than primary intervention.
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