A nurse is evaluating a telemetry strip that shows an irregularly irregular rhythm, no identifiable P waves, and a ventricular rate of 110/min.
The client reports palpitations. How should the nurse document this strip in the medical record?

Disseminated intravascular coagulation is a complex secondary complication of sepsis. Knowledge of the coagulation cascade, specifically the paradoxical relationship between widespread microvascular clotting and systemic hemorrhage due to the depletion of clotting factors and fibrinogen, is necessary to explain this condition.

Choice A rationale

DIC begins with excessive thrombin generation, leading to widespread fibrin deposition in the microcirculation. This process consumes clotting factors and fibrinogen, eventually resulting in severe bleeding. It is a disorder characterized by abnormal, systemic activation of coagulation.

Choice B rationale

DIC is characterized by a decreased platelet count, not an elevated one. Platelets are consumed rapidly as they form numerous small clots throughout the body. Thrombocytopenia is a hallmark laboratory finding used to diagnose this life-threatening condition.

Choice C rationale

DIC is an acute, life-threatening complication, not a chronic condition requiring lifelong heparin. While heparin may be used in specific phases to stop the clotting cascade, the primary treatment focuses on resolving the underlying cause, such as sepsis.

Choice D rationale

DIC is an acquired syndrome, not a genetic disorder. While vitamin K is essential for the synthesis of certain clotting factors, the primary pathology of DIC involves the overstimulation of the clotting cascade rather than a simple deficiency.

Patient safety protocols require the application of fall prevention strategies and environmental management. Knowledge of hospital safety standards, mobility mechanics, and the legal implications of restraints is necessary to select interventions that minimize injury risks while maintaining a safe therapeutic environment.

Choice A rationale

Keeping the bed in the lowest position minimizes the vertical distance to the floor, significantly reducing the impact force and potential for injury if a client attempts to exit the bed unassisted. This is a primary fall prevention standard.

Choice B rationale

Dim lighting during daytime hours decreases visual acuity and increases the risk of environmental trips or missteps. Adequate illumination is required for clients to identify obstacles, perceive depth accurately, and navigate their surroundings safely during active hours.

Choice C rationale

Barefoot walking increases the risk of slipping on smooth hospital floor surfaces. Safety protocols mandate non-skid footwear or socks with rubber grips to provide necessary traction and stability, preventing falls related to a lack of foot-to-floor friction.

Choice D rationale

Raising all four side rails is classified as a physical restraint in many jurisdictions and can actually increase injury severity. Clients may attempt to climb over the rails, leading to falls from a much greater height.