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 C
Explanation
Choice A reason: Rapid mood swings are characteristic of bipolar disorder, not OCD. OCD involves intrusive thoughts and compulsive behaviors, like Marty’s hand washing, so this is incorrect for OCD’s primary feature.
Choice B reason: Social withdrawal is more typical of depression or schizophrenia, not OCD. Marty’s persistent thoughts and rituals define OCD, making this incorrect for the disorder’s main characteristic.
Choice C reason: OCD is defined by persistent, unwanted thoughts (obsessions) and repetitive behaviors (compulsions), as seen in Marty’s germ fears and hand washing. This is the correct primary characteristic of OCD.
Choice D reason: Hallucinations and delusions are associated with psychotic disorders, not OCD. Marty’s intrusive thoughts and rituals are classic OCD symptoms, so this is incorrect for the primary feature.
Correct Answer is C
Explanation
Choice A reason: Linking high potassium to kidney function risk is inaccurate; hyperkalemia primarily affects cardiac and neuromuscular function. Numbness, tingling, or weakness are direct symptoms, making this statement less relevant for patient education and incorrect.
Choice B reason: Changing IV fluids may be a treatment but doesn’t explain the issue or engage the patient. Asking to report numbness, tingling, or weakness directly addresses hyperkalemia symptoms, making this less appropriate and incorrect.
Choice C reason: High potassium (6.1 mEq/L) can cause numbness, tingling, or weakness. Instructing the patient to report these symptoms ensures early detection of worsening hyperkalemia, making this the correct, patient-centered statement for education.
Choice D reason: Palpitations may occur, but numbness, tingling, and weakness are more specific to hyperkalemia’s neuromuscular effects. “Quick beating” is less precise for heart rhythm issues, so this is incorrect compared to option c.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.