The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will guide the provider to a diagnosis of DIC?

Prothrombin time, fibrin level and eosinophil count

Fibrin degradation products, lactic acid and complete blood count

D-dimer, fibrinogen and fibrin degradation products

Complete blood count, Complete metabolic panel and prothrombin time

Answer and Explanation

The Correct Answer is C

A.   This test set is incomplete for diagnosing DIC. While PT and fibrinogen are important, the eosinophil count is not a key test for DIC.
B.   While fibrin degradation products are useful, lactic acid is not specific for DIC and may indicate other issues. A complete blood count is helpful but not definitive for diagnosing DIC.
C.   These are key markers for DIC. An elevated D-dimer indicates clot formation and breakdown, while fibrinogen and fibrin degradation products are used to assess clotting and fibrinolysis, both of which are abnormal in DIC.
D.   Complete blood count, complete metabolic panel, and prothrombin time are general tests and can give some clues, but they are not definitive for diagnosing DIC.

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Correct Answer is B

Explanation

A. Fine crackles - Fine crackles are short, popping sounds usually heard during inspiration, indicative of fluid in the lungs.
B. Wheezes - Wheezes are continuous, high-pitched musical sounds caused by narrowed airways, often seen in asthma, bronchitis, or other respiratory conditions.
C. Rhonchi - Rhonchi are low-pitched, rattling sounds that occur when air flows through thick mucus or secretions in the larger airways.
D. Vesicular sounds - Vesicular breath sounds are normal lung sounds heard over most lung fields during inspiration. They are not continuous and high-pitched.

A. count the number of large squares in the R-R interval and divide by 30C B. print a 1-minute ECG strip and count the number of ORS complexes, C. count the number of QRS complexes in 6 seconds and multiply by 10. D. calculate the number of small squares between one QRS complex and the next one and divide by 1500.

Correct Answer is C

Explanation

A. Counting the number of large squares between R-R intervals and dividing by 30 is not the correct method for estimating the ventricular rate on an ECG strip.
B. Printing a 1-minute ECG strip and counting the QRS complexes (option B) is accurate but unnecessary for a quick estimation.
C. The most common and efficient method for estimating the ventricular rate quickly is to count the number of QRS complexes in a 6-second strip (often marked by two dashed lines) and multiply by 10. This gives an estimate of the heart rate per minute.
D. Counting the number of small squares between QRS complexes and dividing by 1500 is the most accurate method but requires more time and precision than counting QRS complexes in 6 seconds.

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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 viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will guide the provider to a diagnosis of DIC?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is C

Explanation

Labs

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The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will guide the provider to a diagnosis of DIC?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

Correct Answer is B

Explanation

When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

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)

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).

Labs

The nurse is planning care for a client diagnosed with heart failure who will soon be discharged home. What should be included in the teaching plan? The client will:

The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

The nurse is caring for a client who received a transfusion of Fresh Frozen Plasma (FFP) for an acute GI bleed related to accidental wantarin overdose. Which laboratory result would indicate the need for an additional unit of Fresh Frozen Plasma (FFP) to correct the problem caused by the overdose?

The nurse has provided teaching to a client who had an implantable cardioverter/defibrillator inserted. Which statement by the client indicates the need for further instruction?