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 C

Explanation

A. Mobitz II is a type of second-degree AV block characterized by constant PR intervals and sudden dropped QRS complexes (i.e., the PR interval does not lengthen progressively). This is a more serious block because the dropped beats are unpredictable and could lead to complete block.
B. Sinus bradycardia is a slower-than-normal heart rate (usually less than 60 beats per minute) that originates from the sinus node. First-degree AV block is characterized by a prolonged PR interval, but unlike second-degree block, there are no dropped QRS complexes.
C. Mobitz I (Wenckebach) is a second-degree AV block where the PR interval gradually lengthens with each successive beat until a QRS complex is dropped. After the dropped beat, the cycle repeats. This is a relatively benign block and often resolves without intervention, though it requires monitoring.
D. Third-degree heart block (also known as complete heart block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently of each other. There are no relationship between the P waves and QRS complexes, and the ventricular rate is typically slower than the atrial rate.

Correct Answer is ["31"]

Explanation

(Volume to be infused (mL) × Drop factor (gtt/mL)) / Time (min).

For the patient prescribed 250 mL of packed red blood cells with a drop factor of 15 gtt/mL over 120 minutes, the calculation would be (250 mL × 15 gtt/mL) / 120 min, which equals 31.25 gtt/min.

Therefore, the nurse should regulate the IV to 31 gtt/min.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

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 caring for a client in the coronary care unit and the monitor depicts the rhythm shown below. What is the nurse’s interpretation of this rhythm?

Correct Answer is C

Explanation

A patient is prescribed 250 mL of packed red blood cells to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

Correct Answer is ["31"]

Explanation

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