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 D

Explanation

A. The 12-lead EKG might be unnecessary right now, especially since the client has no other alarming symptoms. Bumetanide is also not indicated for nausea or tachycardia in this scenario.
B. There is no clear indication that the nausea is related to acid reflux or GI distress that would justify pantoprazole.
C. The tachycardia could be physiological, and treating it with a beta-blocker is unnecessary unless there is a more concerning underlying cause (like heart failure or ischemia). The priority here is not pharmacological intervention but monitoring the client's overall condition.
D. This action allows for appropriate monitoring of the client's condition. Sinus tachycardia may resolve on its own without intervention, and the client doesn't exhibit severe symptoms requiring immediate pharmacologic treatment.

A. Perform carotid massage on the client B. Administer adenosine 12mg IV push STAT C. Prepare the client for electrical cardioversion D. Assess patient and obtain vital signs

Correct Answer is D

Explanation

A. Carotid massage can be used as a vagal maneuver for certain types of supraventricular tachycardia (SVT), particularly in stable patients. However, it is not recommended in cases where the patient has a history of cocaine use or is showing signs of instability because of the potential for triggering a serious event, like a stroke.
B. Adenosine is a medication commonly used for the treatment of SVT. However, it should be given with caution and only after assessing the patient's condition. In this case, the patient needs to be assessed first, including vital signs, level of consciousness, and overall stability, before any medications are administered.
C. Electrical cardioversion is indicated for unstable SVT (e.g., signs of hemodynamic instability such as hypotension, chest pain, or altered mental status). However, this patient is only reporting a "racing heart" and nervousness and has not yet been assessed for vital signs or other clinical symptoms.
D. The first step in this case should be to assess the patient's condition. This includes checking the vital signs, level of consciousness, and overall stability. Once this initial assessment is performed, the nurse can then determine whether medications or other interventions (like adenosine or cardioversion) are needed.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL

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

Correct Answer is D

Explanation

Correct Answer is D

Explanation

Labs

Company

Resources

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?

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Naxlex Comprehensive Predictor Exams

The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but complains of slight nausea after eating breakfast. What is the nurse's best action?

Correct Answer is D

Explanation

A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Correct Answer is D

Explanation

Labs

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