You are caring for a patient with sepsis who has developed disseminated intravascular coagulation (DIC). Which assessments should you prioritize? (Select all that apply)
Urine output
White blood cell count
Level of consciousness
Weight
Oxygen saturation
Correct Answer : A,C,E
Choice A reason: Monitoring urine output is critical in sepsis-induced DIC, as it reflects renal perfusion and organ function. Decreased output may indicate hypoperfusion or acute kidney injury from microthrombi, common in DIC, making this a priority assessment to guide fluid and supportive therapy.
Choice B reason: White blood cell count is relevant in sepsis but less specific for DIC progression. It indicates infection severity but does not directly assess DIC’s coagulopathy or organ impact, making it a lower-priority assessment compared to organ function indicators.
Choice C reason: Level of consciousness is a priority, as DIC can cause cerebral microthrombi or hemorrhage, leading to neurological changes. Altered consciousness signals potential brain involvement or systemic hypoperfusion, necessitating immediate intervention, making this a critical assessment in sepsis with DIC.
Choice D reason: Weight assessment is not a priority in acute sepsis with DIC, as it does not directly reflect coagulopathy or organ dysfunction. Fluid shifts may occur, but urine output and other vital signs are more immediate indicators, making this non-essential.
Choice E reason: Oxygen saturation is crucial, as DIC can impair pulmonary perfusion through microthrombi, causing hypoxemia. Sepsis also increases oxygen demand, and low saturation indicates respiratory compromise, making this a priority assessment to ensure adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Blood in the chest cavity is a hemothorax, not a pneumothorax. Pneumothorax involves air entering the pleural space, disrupting lung expansion, while hemothorax involves blood accumulation, making this an incorrect explanation.
Choice B reason: A pneumothorax is air in the pleural space, causing lung collapse due to disrupted negative pressure. This can result from trauma or spontaneous rupture, leading to respiratory distress, making this the correct explanation of the condition.
Choice C reason: Pus in the pleural space is an empyema, typically from infection, not a pneumothorax. Pneumothorax involves air, not purulent fluid, causing lung collapse, making this an incorrect description of the condition.
Choice D reason: Collapse of small airways occurs in conditions like bronchiolitis, not pneumothorax. Pneumothorax involves air in the pleural cavity, not airway obstruction, leading to lung collapse, making this an incorrect explanation.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Red blood cells are not a direct measure of inflammation; they assess anemia or oxygen-carrying capacity. Inflammation is measured by WBC, ESR, and fever, which reflect immune activity and systemic response, so this is incorrect for inflammation measurement.
Choice B reason: White blood cells (WBC) increase during inflammation (leukocytosis), indicating immune activation. This is a standard laboratory measure of inflammatory processes, making it a correct choice for assessing inflammation in clinical practice.
Choice C reason: Erythrocyte sedimentation rate (ESR) measures how quickly red blood cells settle, rising with inflammation due to increased proteins. It’s a common marker for inflammatory conditions, making it a correct selection for measuring inflammation.
Choice D reason: Fever is a clinical sign of inflammation, driven by cytokines like IL-6. It’s a systemic response measured via temperature, making it a correct choice for assessing inflammation alongside laboratory markers like WBC and ESR.
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