The nurse is caring for a client diagnosed with disseminated intravascular coagulation (DIC). When completing an assessment for decreased perfusion from clotting, the nurse would observe for which manifestation?

Cyanosis

Petechiae

Epistaxis

Hematuria

Answer and Explanation

The Correct Answer is A

A.   Cyanosis, or a bluish discoloration of the skin, occurs when there is insufficient oxygen in the blood, which can result from decreased perfusion due to clotting in DIC. It is a sign of poor oxygenation and perfusion.
B.   While petechiae (small red or purple spots) are a common manifestation of DIC due to microvascular clotting and bleeding, they are not a sign of decreased perfusion.
C.   Epistaxis (nosebleeds) is another bleeding manifestation of DIC but is not indicative of decreased perfusion, which is more closely related to cyanosis.
D.   Hematuria (blood in the urine) can occur in DIC due to clotting in the kidneys or urinary tract. However, it is more related to bleeding than to decreased perfusion.

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Correct Answer is ["11"]

Explanation

The patient weighs 121 lbs, which is approximately 55 kilograms (121 ÷ 2.2).

Next, multiply the patient's weight in kilograms by the dosage prescribed, which is 20 units/kg. This results in a total dosage of 1100 units (55 kg × 20 units/kg).

The medication is supplied as 25,000 units in 250 mL, so to find out how many mL of medication is needed, set up a proportion: 25,000 units is to 250 mL as 1100 units is to X mL. Solving for X gives you 11 mL (1100 units × 250 mL ÷ 25,000 units).

Therefore, the nurse will administer 11 mL of Heparin to the patient.

A. Consume 2500mL of fluids per day during the summer months B. Maintain daily sodium intake of no more than 2gm per day C. Notify the health care provider if weight increases by 5 Ibs. in one week D. If shortness of breath occurs with minimal activity, notify the provider E. Take furosemide anytime when feeling bloated or short of breath

Correct Answer is ["B","C","D"]

Explanation

A. Fluid intake may need to be regulated in heart failure patients, consuming 2500mL of fluids per day may be too high for some patients, depending on their condition and whether they are on fluid restriction. Fluid management should be individualized, and the provider should specify the amount based on the patient's condition.
B. A low-sodium diet is essential for heart failure patients to help reduce fluid retention, decrease blood pressure, and lessen the burden on the heart. The American Heart Association recommends a sodium intake of no more than 2,000-2,300 mg per day for heart failure patients.
C. Rapid weight gain is a sign of fluid retention, which can indicate worsening heart failure. A gain of 2-3 pounds in a single day or 5 pounds in a week should prompt the client to contact their healthcare provider for further evaluation.
D. Shortness of breath with minimal activity can be a sign of worsening heart failure or fluid overload. This symptom should be reported immediately to a healthcare provider for further evaluation and possible adjustments to treatment.
E. Furosemide (a diuretic) is often prescribed to reduce fluid retention but it should not be taken without proper guidance or as a response to symptoms without consulting the healthcare provider. Taking diuretics at the wrong time or in excessive amounts can lead to dehydration and electrolyte imbalances, which could worsen the condition.

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The nurse is caring for a client diagnosed with disseminated intravascular coagulation (DIC). When completing an assessment for decreased perfusion from clotting, the nurse would observe for which manifestation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 121 Ibs. The medication is supplied as 25,000 units/250 mL. How many Ml will the nurse give? (round to the nearest whole number)

Correct Answer is ["11"]

Explanation

The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).

Correct Answer is ["B","C","D"]

Explanation

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