Susan, the nurse, is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?

Vitamin K

Statin

Heparin

Metformin

Answer and Explanation

The Correct Answer is C

Choice A: Vitamin K
Vitamin K is essential for the synthesis of clotting factors and is often used to treat bleeding disorders caused by vitamin K deficiency or to reverse the effects of anticoagulants like warfarin. However, in the context of disseminated intravascular coagulation (DIC), the primary issue is not a deficiency of clotting factors but rather an overactivation of the clotting cascade leading to both clot formation and bleeding. Therefore, while vitamin K can be beneficial in certain bleeding disorders, it is not the primary treatment for DIC.

Choice B: Statin
Statins are medications used to lower cholesterol levels and reduce the risk of cardiovascular disease. They work by inhibiting the enzyme HMG-CoA reductase, which plays a crucial role in cholesterol synthesis. Statins are not used in the management of DIC as they do not address the underlying pathophysiology of the condition, which involves widespread clotting and subsequent bleeding.

Choice C: Heparin
Heparin is an anticoagulant that helps prevent the formation of new clots and the extension of existing clots. In the management of DIC, heparin can be used to interrupt the clotting process and prevent further consumption of clotting factors. This can help stabilize the patient and reduce the risk of severe bleeding. Heparin is particularly useful in cases where thrombosis is predominant. It is important to monitor the patient closely to balance the risk of bleeding with the benefits of anticoagulation.

Choice D: Metformin
Metformin is an oral hypoglycemic agent used to manage type 2 diabetes by improving insulin sensitivity and reducing glucose production in the liver. It has no role in the treatment of DIC, as it does not affect the coagulation pathways or the underlying causes of DIC.

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Correct Answer is C

Explanation

Choice A Reason:
Establishing IV access and starting fluid replacement is important for maintaining hemodynamic stability, especially if there is significant blood loss. However, it is not the immediate priority in this scenario. Ensuring the neck is stabilized takes precedence to prevent potential spinal cord injury.

Choice B Reason:
Inserting a nasogastric tube is not a priority in the acute management of a trauma patient with a head injury. This procedure can be deferred until the patient's airway and cervical spine are secured and other life-threatening conditions are addressed.

Choice C Reason:
Keeping the neck stabilized is the priority action. In a trauma patient with a head injury, there is a high risk of cervical spine injury. Stabilizing the neck prevents further damage to the spinal cord, which could result in paralysis or other severe complications.

Choice D Reason:
Monitoring pulse and blood pressure frequently is essential for assessing the patient's hemodynamic status. However, it is not the immediate priority over stabilizing the cervical spine. Once the neck is stabilized, continuous monitoring of vital signs should follow.

A. Difficulty swallowing B. Pain of 6 on a scale of 0 to 10 C. Heart rate 122/min D. Urinary output 25 mL/hr

Correct Answer is A

Explanation

Choice A Reason:
Difficulty swallowing is a critical finding in a client with burns to the face, ears, and eyelids. This symptom can indicate airway edema or obstruction, which is a life-threatening condition. Burns in these areas can cause significant swelling, leading to compromised airways. Immediate intervention is required to secure the airway and prevent respiratory failure.

Choice B Reason:
Pain of 6 on a scale of 0 to 10 is important to manage for patient comfort and to prevent complications related to pain, such as increased heart rate and blood pressure. However, it is not the immediate priority over potential airway compromise. Pain management can be addressed once the airway is secured.

Choice C Reason:
A heart rate of 122/min indicates tachycardia, which can be a response to pain, stress, or hypovolemia. While it is important to monitor and manage, it is not as immediately life-threatening as airway obstruction. Tachycardia can be addressed after ensuring the airway is clear.

Choice D Reason:
Urinary output of 25 mL/hr is below the normal range (typically 30-50 mL/hr) and can indicate dehydration or renal impairment. While this is a concerning finding, it is not the immediate priority compared to securing the airway. Fluid resuscitation and renal function can be managed once the airway is stabilized.

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Susan, the nurse, is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?

Nursing Test Bank

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