The nurse would assess the client diagnosed with disseminated intravascular coagulation (DIC) for which manifestation of the disorder?

Petechiae

Diarrhea

Intractable vomiting

Urinary incontinence

Answer and Explanation

The Correct Answer is A

A.   Petechiae (small, pinpoint hemorrhages) are a common manifestation of DIC due to the excessive clotting and subsequent breakdown of clotting factors, leading to bleeding into the skin.
B.   Diarrhea is not typically a primary symptom of DIC, although gastrointestinal bleeding can occur in severe cases.
C.   Intractable vomiting is not characteristic of DIC, although it could occur in clients with severe bleeding or complications.
D.   Urinary incontinence is not a direct manifestation of DIC, although it could occur secondary to neurological or other systemic complications.

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Correct Answer is ["A","C","D"]

Explanation

A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.

A. weigh the client to obtain a baseline for comparison B. Insert an indwelling catheter C. Draw blood for chemistry studies and a CBC D. Administer furosemide 40mg PO

Correct Answer is A

Explanation

A. Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B. Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C. Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D. Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

The nurse would assess the client diagnosed with disseminated intravascular coagulation (DIC) for which manifestation of the disorder?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

Correct Answer is A

Explanation

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