A client who experiences multiple traumatic injuries begins to ooze blood from an injection site. Which additional finding should the nurse identify that supports an early indication of disseminated intravascular coagulation (DIC)?

Bleeding from oral mucosa.

Shorter clotting times.

Negative D-dimer test.

Edema of the extremities.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Bleeding from oral mucosa: Unexplained or excessive bleeding from mucous membranes, such as the mouth, is an early sign of DIC. It indicates widespread activation of the coagulation cascade, consuming clotting factors and platelets, which leads to bleeding at multiple sites.

B. Shorter clotting times: DIC is characterized by prolonged clotting times (PT, aPTT) due to consumption of clotting factors, not shortened times. Shorter clotting times would not support the diagnosis.

C. Negative D-dimer test: D-dimer is typically elevated in DIC because of fibrin degradation. A negative D-dimer would not support an early indication of DIC.

D. Edema of the extremities: Edema may occur from fluid shifts or injury but is not a specific or early sign of DIC. It does not directly reflect coagulation abnormalities.

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Free Nursing Study Resources

Correct Answer is ["D","E","F"]

Explanation

Rationale:
A. Induce hypotension with diuretics: Lowering blood pressure intentionally can reduce cerebral perfusion pressure (CPP), worsening brain ischemia. Maintaining adequate mean arterial pressure (MAP) is essential to ensure sufficient CPP in clients with elevated intracranial pressure (ICP).

B. Avoid sedatives or pain medication: Pain and agitation increase ICP; sedatives and analgesics are often used to reduce these responses and help optimize CPP. Avoiding them can be detrimental rather than protective.

C. Keep the knees bent: Flexing the hips and knees can increase intra-abdominal and intrathoracic pressure, which may elevate ICP and compromise venous return from the brain. Keeping the legs straight or slightly elevated is generally preferred.

D. Position the client with the head of the bed raised: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, reducing ICP and supporting cerebral perfusion. Neutral head positioning without rotation also optimizes venous outflow.

E. Manage the client's fever with cooling blankets: Fever increases cerebral metabolic demand, which can worsen cerebral hypoxia and elevate ICP. Controlling temperature helps maintain optimal cerebral oxygenation and CPP.

F. Bundle nursing care to avoid over-stimulating the client: Minimizing frequent, fragmented interventions prevents sudden ICP spikes caused by pain, agitation, or movement. Bundling care supports stable ICP and maintains cerebral perfusion.

Correct Answer is ["120"]

Explanation

Calculation:

Identify the prescribed rate and IV concentration

Prescribed Rate: 4 mg/min

IV Concentration: 1 gram in 500 mL

1 gram = 1,000 mg

Convert the prescribed rate to mg/hr

4 mg/min × 60 min = 240 mg/hr

Calculate the infusion rate in mL/hr

Infusion Rate (mL/hr) = (Prescribed Dose per hour ÷ Total Dose in Bag) × Total Volume

Infusion Rate = (240 ÷ 1,000) × 500

Infusion Rate = 0.24 × 500

Infusion Rate = 120 mL/hr

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A client who experiences multiple traumatic injuries begins to ooze blood from an injection site. Which additional finding should the nurse identify that supports an early indication of disseminated intravascular coagulation (DIC)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In addition to the pharmacological treatment, which action(s) could the nurse do to help to optimize the client's cerebral perfusion pressure? Select all that apply.

Correct Answer is ["D","E","F"]

Explanation

The healthcare provider (HCP) prescribes lidocaine 4 mg/minute IV for a client experiencing premature ventricular contractions (PVCS). The IV bag contains lidocaine 1 gram in 500 mL DW. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only)

Correct Answer is ["120"]

Explanation

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