The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

Hepatomegaly.

Splenomegaly.

Anuria.

Ecchymosis.

Answer and Explanation

The Correct Answer is D

Choice A reason: Hepatomegaly, or enlarged liver, is not a typical finding in DIC. While DIC can affect multiple organs due to widespread microvascular thrombosis and bleeding, hepatomegaly is more commonly associated with other conditions such as liver diseases or congestive heart failure.

Choice B reason: Splenomegaly, or enlarged spleen, is also not a common finding in DIC. Although the spleen can be involved in various hematologic disorders, DIC primarily affects the coagulation and fibrinolytic systems, leading to bleeding and clotting issues rather than spleen enlargement.

Choice C reason: Anuria, or absence of urine production, can occur in severe cases of DIC due to acute kidney injury from microvascular thrombosis or bleeding. However, it is not as common a finding as petechiae, bleeding gums, and ecchymosis. Anuria indicates a critical state requiring immediate intervention but is not the primary expected finding in DIC.

Choice D reason: Ecchymosis, or bruising, is a common finding in DIC. DIC involves widespread activation of the coagulation cascade leading to the consumption of clotting factors and platelets, resulting in bleeding manifestations such as petechiae, bleeding gums, and ecchymosis. These signs indicate the body's inability to form stable clots and the presence of spontaneous bleeding.

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Correct Answer is D

Explanation

Choice A reason: The statement "Headaches can occur due to the vasoconstriction effect of the medication" is incorrect. Nitroglycerin causes vasodilation, not vasoconstriction. Vasodilation increases blood flow, which can lead to headaches as a common side effect.

Choice B reason: Offering Morphine to manage the headache is not the most appropriate initial response. While Morphine can relieve pain, it's essential to educate the patient about the common side effects of Nitroglycerin and provide reassurance. Morphine use should be carefully considered and is typically reserved for more severe pain management.

Choice C reason: Notifying the physician immediately is not necessary in this scenario, as a headache is a known and common side effect of Nitroglycerin. It's more appropriate to educate the patient about the side effects and provide reassurance. Only if the headache is severe and unrelieved by other measures should the physician be notified.

Choice D reason: Explaining that the headache is a normal side effect of Nitroglycerin, which dilates blood vessels, is the most appropriate response. This helps to reassure the patient and provides an understanding of why the headache is occurring. Nitroglycerin works by dilating blood vessels to improve blood flow and reduce angina symptoms, and headaches are a common side effect due to this vasodilation.

A. Provide at least 5000 kcal/day. B. Start an oral diet on the first day. C. Administer a diet high in protein. D. Collaborate with a registered dietitian. E. Offer frequent high-calorie snacks.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Providing at least 5000 kcal/day is essential for a patient with burn injuries. Burns significantly increase the body's metabolic rate and caloric needs to support the healing process and prevent catabolism. Ensuring an adequate caloric intake helps meet the energy demands required for tissue repair and recovery.

Choice B reason: Starting an oral diet on the first day may not be appropriate for all burn patients, particularly those with extensive burns or those who are not yet stable. Nutrition needs should be carefully assessed, and feeding may begin via alternative methods such as enteral nutrition until the patient is ready for oral intake.

Choice C reason: Administering a diet high in protein is crucial for burn patients, as protein is essential for wound healing, maintaining lean body mass, and supporting the immune system. Protein intake should be increased to help repair damaged tissues and promote recovery.

Choice D reason: Collaborating with a registered dietitian is important to create an individualized nutrition plan that meets the specific needs of the burn patient. A dietitian can provide expertise in calculating caloric and protein requirements, recommending appropriate supplements, and monitoring the patient's nutritional status.

Choice E reason: Offering frequent high-calorie snacks helps ensure that the patient meets their increased caloric needs. Small, frequent meals and snacks can be more manageable for patients with reduced appetite or those who have difficulty consuming large meals. High-calorie snacks provide additional energy to support healing and recovery.

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The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with angina is receiving Nitroglycerin and begins to complain of a severe headache. What is the most appropriate response from the nurse?

Correct Answer is D

Explanation

A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

After a diagnosis of chronic kidney disease (CKD), the client was started on epoetin. Which finding indicates that the medication has been effective?

A nurse cares for a patient recovering from mechanical valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?

The 75-year-old client is hospitalized with end-stage chronic kidney disease. Which of the following serum lab findings would the nurse expect? Select all that apply.

Considering the patient's esophageal varices, which of the following nursing interventions would be appropriate in your care of the patient?

The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following cues should the nurse assess to determine if the client is experiencing a myocardial infarction? Pick 2 answers.