A nurse is assessing a client who has sepsis. Which of the following findings should the nurse identify as an indication that the client has developed disseminated intravascular coagulation?
Decreased oxygen saturation
Hypertension
Bradycardia
Increased urine output
The Correct Answer is A
Rationale:
A. Decreased oxygen saturation: Disseminated intravascular coagulation (DIC) leads to widespread clotting and subsequent bleeding, impairing oxygen delivery to tissues. Microthrombi can block pulmonary vessels, reducing gas exchange and causing hypoxia.
B. Hypertension: DIC is typically associated with hypotension due to systemic inflammation, blood loss, and poor perfusion, not hypertension. Shock states in sepsis and DIC often cause a drop in blood pressure.
C. Bradycardia: Clients with sepsis and DIC are more likely to develop tachycardia in response to hypotension and poor oxygenation. Bradycardia is not characteristic of DIC and may indicate a different or late-stage complication.
D. Increased urine output: DIC often results in decreased urine output due to renal hypoperfusion and possible acute kidney injury. Increased output would be atypical in a client with progressing DIC.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Health Insurance Portability and Accountability Act of 1996: HIPAA regulates the protection and confidentiality of patient health information. It does not address employee vaccination requirements or workplace safety related to infectious disease exposure.
B. Occupational Safety and Health Administration: OSHA requires employers to offer the hepatitis B vaccine to all employees who may be exposed to blood or other infectious materials. This is part of its Bloodborne Pathogens Standard to reduce occupational risk.
C. Professional standards review organization: These groups evaluate the quality and efficiency of care provided by healthcare institutions but are not regulatory bodies for workplace safety or immunization protocols.
D. Emergency Medical Treatment and Active Labor: EMTALA ensures public access to emergency services regardless of ability to pay. It is not related to employee vaccination or workplace infection control policies.
Correct Answer is C
Explanation
Rationale:
A. Obtain the client's serum ammonia level: Serum ammonia levels are typically monitored in clients with liver dysfunction or hepatic encephalopathy, not in early sepsis. Ammonia is not a primary marker of tissue hypoperfusion or sepsis-related metabolic changes.
B. Administer glucagon to the client: Glucagon is used primarily to treat hypoglycemia or beta-blocker overdose. It does not play a role in the management or diagnosis of sepsis and would not be indicated in this context.
C. Obtain the client's serum lactate level: Serum lactate is a key indicator in early sepsis, reflecting tissue hypoperfusion and anaerobic metabolism. Elevated lactate levels help identify severity and guide resuscitation efforts, making it an essential early diagnostic step.
D. Administer lactulose to the client: Lactulose is used to treat hepatic encephalopathy by reducing ammonia absorption in the gut. It is not relevant in the early identification or treatment of sepsis and would not address the pathophysiology of the condition.
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