A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Activation of complement pathways.

Inhibition of red blood production.

Production of extra platelets.

Depletion of clotting factors.

Answer and Explanation

The Correct Answer is D

Rationale

A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.

B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.

C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.

D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.

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Correct Answer is B

Explanation

Rationale

A. This intervention is crucial because bariatric surgery can have significant psychological impacts. Many individuals who undergo such procedures may experience changes in mood, body image issues, and emotional challenges. However, it is not a priority

B. Sequential compression stockings are used to prevent deep vein thrombosis (DVT) and promote circulation in clients undergoing surgery, particularly those with obesity who are at higher risk for venous thromboembolism. This intervention is important to prevent serious complications associated with immobility and surgery.

C. This option is not appropriate immediately after gastroplasty. Bariatric surgery, such as gastroplasty, typically involves restrictive procedures that limit the amount of food a person can consume. Providing a wide variety of meal choices contradicts the dietary restrictions and guidelines that are crucial for successful outcomes post-surgery.

D. While urinary incontinence can be a concern in some individuals, it is not directly related to bariatric surgery or the client's primary health concerns of obesity, diabetes mellitus, and hypertension. Monitoring for urinary incontinence may be important in other clinical contexts but is not a priority in the immediate postoperative period of gastroplasty.

A. Notify primary healthcare provider B. Count saturated pads per hour C. Administer 2 units of packed red blood cells (PRBC) D. Administer 0.2 mg methylergonovine IM E. Insert straight catheter F. Alert the emergency response team G. Increase the IV fluid to maximum rate H. Weigh all bloody materials I. Massage fundus until firm

Correct Answer is ["A","B","D","F","G","I"]

Explanation

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B. Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C. Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D. Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E. Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F. Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G. Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H. Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I. Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.

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A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Correct Answer is ["A","B","D","F","G","I"]

Explanation

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