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 A

Explanation

A. This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B. Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C. Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D. Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Ventricular fibrillation (VF) is characterized by a chaotic, rapid, and irregular electrical activity on the ECG, with no identifiable QRS complexes, P waves, or T waves. The heart quivers ineffectively, leading to no blood flow or cardiac output, which results in rapid loss of consciousness and is life-threatening.

Immediate defibrillation is required to restore a normal rhythm. A high-energy shock is delivered to the heart to reset the electrical activity, potentially allowing the heart's natural pacemaker to regain control and resume normal function.

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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

The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

Correct Answer is A

Explanation

Complete the following sentences with the list of drop down The nurse assesses the client's rhythm on the monitor. The patient is unresponsive with no pulse. The nurse identifies the rhythm asdropdown. The nurse's priority action isdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

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