A client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits:

Systolic blood pressure greater than 70 mm Hg

Stable level of consciousness

Urine output greater than or equal to 30 mL/hour

Decreased bleeding

Answer and Explanation

The Correct Answer is D

Reasoning:

Choice A reason: Systolic blood pressure above 70 mm Hg is a goal in hypovolemia but is not the most specific outcome for DIC-related bleeding. While low blood pressure reflects fluid loss, addressing bleeding directly prevents further volume depletion, making reduced bleeding a more targeted and measurable outcome.

Choice B reason: A stable level of consciousness is important but not directly tied to deficient fluid volume from bleeding in DIC. Altered consciousness may result from cerebral ischemia or hyponatremia, but reducing bleeding is the primary goal to stabilize fluid volume and prevent further hemodynamic compromise.

Choice C reason: Urine output of 30 mL/hour or more indicates adequate renal perfusion but is a secondary outcome in DIC-related bleeding. While it reflects fluid status, directly addressing bleeding through interventions like transfusions or clotting factor replacement is more specific to correcting the underlying fluid volume deficit.

Choice D reason: Decreased bleeding is the most appropriate outcome for deficient fluid volume in DIC, as bleeding from mucosal and venipuncture sites directly causes volume loss. Reducing hemorrhage through platelet or factor replacement stabilizes fluid volume, preventing hypovolemia and its complications, making this the most measurable and relevant outcome.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: A blood pressure of 150/90 mm Hg is not an absolute contraindication for thrombolytic therapy. While hypertension must be controlled (below 185/110 mm Hg) before thrombolytics, it is manageable with medication, unlike hemorrhagic stroke, which poses an immediate and absolute risk of worsening bleeding.

Choice B reason: Previous thrombolytic therapy within 12 months is not an absolute contraindication. Guidelines restrict thrombolytics within a shorter timeframe (e.g., recent major surgery), but prior therapy alone does not preclude use. Hemorrhagic stroke is a definitive contraindication due to the risk of catastrophic bleeding.

Choice C reason: Evidence of hemorrhagic stroke is an absolute contraindication for thrombolytic therapy, as thrombolytics like tPA dissolve clots, increasing bleeding in an already hemorrhagic brain. This risks worsening intracranial hemorrhage, leading to neurological deterioration or death, making it a critical exclusion criterion.

Choice D reason: Evidence of stroke evolution, such as progressing symptoms, is not an absolute contraindication. It may influence timing or eligibility, but thrombolytics can still be used within the time window if ischemic. Hemorrhagic stroke is a definitive barrier due to bleeding risk.

A. Chest radiograph B. ECG C. CBC D. Antibiotic

Correct Answer is C

Explanation

Reasoning:

Choice A reason: A chest radiograph evaluates lung or cardiac issues but is not the first test for symptoms of tiredness, coldness, and shortness of breath with tachycardia. These suggest anemia, and a CBC directly assesses hemoglobin and red blood cell counts, making it more relevant than imaging for initial evaluation.

Choice B reason: An ECG assesses cardiac rhythm and ischemia, useful for tachycardia, but it does not address the underlying cause of fatigue, coldness, and dyspnea. These symptoms suggest anemia, and a CBC is needed to confirm low hemoglobin before evaluating cardiac function with an ECG.

Choice C reason: A complete blood count (CBC) is the most appropriate test, as tiredness, coldness, shortness of breath, and tachycardia suggest anemia. A CBC measures hemoglobin, hematocrit, and red blood cell indices, identifying anemia’s presence and type, guiding further diagnostic and therapeutic interventions for the client’s symptoms.

Choice D reason: Antibiotics treat infections, but tiredness, coldness, dyspnea, and tachycardia point to anemia, not infection. Without fever or infection signs, antibiotics are inappropriate. A CBC is needed to confirm anemia as the cause, making it the priority over empirical antibiotic therapy.

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Naxlex Comprehensive Predictor Exams

A client is brought by ambulance to the ED after experiencing what the family thinks is a stroke. The nurse caring for this client is aware that which is an absolute contraindication for thrombolytic therapy?

Correct Answer is C

Explanation

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the health care provider to order?

Correct Answer is C

Explanation

A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?

A client’s family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?

A client comes to the clinic reporting fatigue. Laboratory findings reveal a low serum iron level, a low transferrin saturation, and a low ferritin level. Which type of anemia does the nurse suspect that correlates with these laboratory findings?

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?

The nurse providing care for a client with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk?