The nurse would assess the client diagnosed with disseminated intravascular coagulation (DIC) for which manifestation of the disorder?

Petechiae

Diarrhea

Intractable vomiting

Urinary incontinence

Answer and Explanation

The Correct Answer is A

A.   Petechiae (small, pinpoint hemorrhages) are a common manifestation of DIC due to the excessive clotting and subsequent breakdown of clotting factors, leading to bleeding into the skin.
B.   Diarrhea is not typically a primary symptom of DIC, although gastrointestinal bleeding can occur in severe cases.
C.   Intractable vomiting is not characteristic of DIC, although it could occur in clients with severe bleeding or complications.
D.   Urinary incontinence is not a direct manifestation of DIC, although it could occur secondary to neurological or other systemic complications.

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Correct Answer is C

Explanation

A. While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B. This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C. When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D. While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

A. 20-gauge catheter in the right wrist infusing IV antibiotics B. 18-gauge catheter infusing 20 mEq Potassium Chloride IV C. 22-gauge catheter in the left forearm infusing 0.9% Normal Saline D. 20-gauge catheter in the right forearm infusing 0.9% Normal Saline

Correct Answer is D

Explanation

A. The 20-gauge catheter in the right wrist is not ideal for blood transfusions, as wrist veins are smaller and may be less optimal for high-flow transfusions.
B. An 18-gauge catheter is appropriate for blood transfusions, but the catheter is currently in use for potassium chloride, which would need to be discontinued. The best choice is a separate site.
C. A 22-gauge catheter is not large enough for blood transfusion; it may cause hemolysis or slow the transfusion rate.
D. The 20-gauge catheter in the right forearm is an appropriate size for a blood transfusion and is currently infusing normal saline, which does not interfere with the blood transfusion.

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The nurse would assess the client diagnosed with disseminated intravascular coagulation (DIC) for which manifestation of the disorder?

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Naxlex Comprehensive Predictor Exams

The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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