2nd exam

The nurse is caring for a client with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this client? · Restrict visitors with communicable illnesses. B. Restrict fluid intake. C. Replace hand hygiene with gloves. D. Insert an indwelling urinary catheter to prevent skin breakdown.

A

The nurse has determined the client with DIC is experiencing pain. Which interventions will the nurse provide to support the client in pain? (Select all that apply.) A: Continuously monitoring oxygen saturation and oxygen administration as ordered B: Encouraging frequent turning and coughing C: Using standard pain scale to evaluate and monitor pain and analgesic effectiveness D: Applying cool compresses to painful joints E: Handling extremities gently

CDE

The nurse concludes that both clotting and bleeding occur during disseminated intravascular coagulation (DIC) due to which process? A. Tissue damage from bleeding uses up clotting factors quicker than they can be replaced. B. Activation of intrinsic pathways results in release of excess clotting factors. C. Only clotting occurs during​ DIC, as clotting factors are replaced and available to prevent excess bleeding. D. Excess release of thrombin uses up clotting factors quicker than they can be replaced.

D

The nurse is preparing a presentation that will include manifestations of HELLP syndrome A. "Laboratory results will show that the liver enzymes will be low." B. "Laboratory results will reveal slightly elevated hemoglobin." C. "Laboratory results will reveal an elevated hematocrit." D. "Laboratory results will show that the platelet count is low."

D

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply.. A) Monitor the client's level of consciousness and mental status. B) Elevate the client's knees on the bed or with a pillow. C) Minimize the use of tape on the client's skin. D) Assess extremity pulses, warmth, and capillary refill. E) Carefully reposition the client at least every 2 hours

acd

The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of a. a decrease in fibrin degradation products. b. an increased D-dimer level. c. thrombocytopenia d. low fibrinogen levels.

b. an increased D-dimer level.

You're providing an in-service to a group of new labor and delivery nurse graduates about the pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they understood how this condition develops? A. "The basal arteries of the myometrium fail to widen to support blood flow to the placenta." B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter." C. "The cardiovascular system of the mother fails to compensate for the increased blood flow from the fetus and placental ischemia occurs." D. "If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia."

B When preeclampsia occurs it is because the spiral arteries of the uterus failed to widen in diameter due to poor trophoblast invasion during the beginning of the pregnancy. Overtime, this causes problems (usually after 20 weeks gestation) and the placenta experiences ischemia. When the placenta becomes ischemic is releases substances into mom's circulation that are very toxic to her endothelial cells, which causes all the signs and symptoms seen in preeclampsia. Severity varies in patients.

A critically ill patient has been diagnosed with disseminated intravascular coagulation (DIC). What pattern of abnormal laboratory results does the nurse expect? Select all that apply. A) Low absolute neutrophil count and red blood cell count b) High prothrombin time (PT) and partial thromboplastin time (PTT) c) Increased fibrin degradation products and presence of D-dimers D) Decreased fibrinogen and thrombocytes E) Increased fibrinogen and fibrin degradation products F) Decreased total white cell count and hematocrit

BCD

Select all the risk factors below that increases a woman's risk for developing preeclampsia: A. Nulligravida B. Primigravida C. BMI 34 D. Pregnant with twins E. Maternal history of preeclampsia F. Age: 25-years-old G. History of Lupus and Diabetes

BCDE Risk factors for preeclampsia include: History of preeclampsia or family history, first pregnancy (primigravida), significant health history prior to pregnancy: diabetes, lupus, high blood pressure, kidney disease, Obese: BMI >30, having more than one baby (twins, triplets etc.), age (young <18 or advanced >35)

What should a nurse be careful to observe for when assessing a patient with thrombocytopenia? a. Distended neck veins and skin discoloration b. Discoloration of the nails and sclera c. Petechiae on the skin and bleeding gums d. Enlarged thyroid gland and excitability

C

Which laboratory result is consistent with a diagnosis of thrombocytopenia? A) Hemoglobin 13 B) Hemoglobin 16 C) Platelets 20,000 Platelets 1,000,000

C

What is the therapeutic level for magnesium sulfate? 4-7 mEq/L

4-7 mEq/L

A nurse is planning care for a client with leukemia. The nurse chooses "Risk for Bleeding" as the nursing diagnosis. Which interventions support this nursing diagnosis? Select all that apply. A. Limit parenteral injections. B. Encourage client to deep breathe and huff cough frequently. C. Apply pressure to arterial puncture sites for 5 minutes. D. Use nonelectric razor when providing grooming for client. E. Educate client to not strain during bowel movements.

A,E

A client has disseminated intravascular coagulation (DIC). Which clinical manifestation should the nurse expect to observe? (Select all that apply.) A. Joint pain B hypertension C. Petechiae D. Bleeding E. Clotting

ACDE

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipunctures. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.

B

The nurse is caring for a patient with suspected disseminated intravascular coagulation (DIC). Which diagnostic test result supports this suspicion? A. Shortened prothrombin time B. Increased platelets C. Presence of schistocytes in CBC D. Increased fibrinogen levels

C Presence of schistocytes in CBC

The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client? A) Heart rate 110 beats per minute B) Oxygen saturation level 86% C) Urine output 20 mL per hour D) No evidence of bleeding

No evidence of bleeding

A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia? A) Urine protein 300 mg/24 hours B) Blood pressure 150/96 mm Hg C) Mild facial edema D) Hyperreflexia

• Hyperreflexia

The nurse is teaching a patient and the spouse about home care for acute disseminated intravascular coagulation (DIC). Which statement by the patient's spouse indicates understanding?

"I will call my spouse's healthcare provider if there is any blood in my spouse's urine.

The nurse instructs a patient with thrombocytopenia about safety measures. Which statement made by the patient indicates the need for further instruction? "I will take aspirin if I have a headache."

"I will take aspirin if I have a headache."

Which assessment findings, experienced by the client at 36 weeks' gestation, would the nurse document as diagnostic signs of severe preeclampsia? Select all that apply. +1 proteinuria Blood pressure of 164/110 mm Hg Elevated serum creatinine Elevated liver enzymes

+1 proteinuria Blood pressure of 164/110 mm Hg Elevated serum creatinine Elevated liver enzymes

A patient presents to the clinic with possible immune thrombocytopenic purpura (ITP) due to a rash on the upper legs and arm and is also recovering from a bad case of strep throat. The patient has no significant medical history. The nurse should anticipate which medication will be administered to this patient?

- Prednisone

The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? 1. Blood pressure of 142/92 2. Weight gain of 16oz per week 3. Pulse of 92 beats per minute 4. Respiratory rate of 24 per minute

1

The nurse assesses a client who has bacterial pneumonia and finds tachycardia, hypotension, oliguria, and acrocyanosis of a foot. Schistocytes are found in a complete blood count, and the D-dimer is elevated. Which collaborative action should the nurse anticipate? A. Heparin therapy B. Warfarin therapy C. Dialysis D. Foot amputation

A

The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client? A) Carefully repositioning the client every 2 hours B) Administering oxygen C) Monitoring oxygen saturation D) Encouraging deep breathing and coughing

A

Which of the following medications may be prescribed for a woman who has been identified to be at risk for developing preeclampsia and HELLP syndrome? a. Low dose aspirin b. Methylernogonovine c. Bupropion d. Calcium gluconate

A

Which strategy should the nurse anticipate implementing during antepartum management of a pregnant client who is hospitalized at 33 weeks of gestation for preeclampsia with severe manifestations? (Select all that apply.) A Fetal surveillance B Ongoing assessment of the need for prompt delivery C Administration of magnesium sulfate D Steroid administration E Activity and dietary restrictions

ABCD

1. The prenatal nurse is completing an assessment of a pregnant client at 36 weeks of gestation who has preeclampsia. Which question is important for the nurse to ask during the assessment? (Select all that apply.) A "Have you had any headaches?" B "Have you experienced any seizures?" C "Have you been having any nausea or vomiting?" D "Have you had any episodes of diarrhea?" E "Have you noticed any changes in your vision?"

ABCE

A 22-year-old male is in the ICU with sepsis. The physicians are trying to rule out acute DIC. The nurse performs a primary assessment of the patient at the beginning of shift. Which of the following items would be part of the initial assessment for this patient? Select all that apply. A) Check for signs of bleeding in the gums and/or mouth. B) Check pupils for reaction. C) Check IV sites or any areas where the patient may have had labs drawn for bleeding D) Check for altered level of consciousness

ACD

The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? SATA. A Vital sign assessment B oxygen 2 liters nasal cannula as prescribed C Seizure precautions D Assessment of intake and output E Assessment of deep tendon reflexes

ACDE

Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are released into mom's circulation, leading to clot formation and then clotting factor depletion.

Abruptio placentae, thromboplastin

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy? Assess deep tendon reflexes.

Assess deep tendon reflexes.

The nurse is planning care for a patient diagnosed with disseminated intravascular coagulation (DIC) who reports pain in the knees. Which assessment should the nurse implement? A. Assess for blood in the stool. B. Assess renal function by monitoring complete blood count C. Observe for bleeding or bruising every 4 hours. D. Observe for wheezing.

Assess for blood in the stool.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

B

Which patient requires the most rapid assessment and care by the emergency department nurse? A. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with thrombocytopenia who has oozing gums after a tooth extraction d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

B

Which diagnostic test can detect destruction of circulating platelets as the cause of thrombocytopenia? 1 Hemoglobin 2 Bone marrow analysis 3 Prothrombin time (PT) 4 Peripheral blood smear

Bone marrow analysis

A client who presents with complaints of easily bruising, bleeding gums, and petechiae may be suffering from what complication of leukemia? A) Thrombocytopenia b) Anemia C) Hepatomegaly D) Neutropenia

D. Thrombocytopenia

A patient with immune thrombocytopenic purpura (ITP) is scheduled for a splenectomy. The goal of the surgery is complete remission. The nurse recognizes that the surgery is an appropriate treatment plan because of what splenic function? 1 The spleen sequesters total platelets. 2 The spleen does not contain macrophages. 3 The spleen does not synthesize any antibodies. 4 The spleen affects the platelet-macrophage interaction.

The spleen affects the platelet-macrophage interaction.

A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for 1. Hemoptysis .2. Focal ischemia. 3. Petechiae. 4. Hematuria

2

A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/L. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

A

The nurse suspects that a patient who has severe sepsis now has disseminated intravascular coagulation (DIC). Which finding, if observed, helps confirm this suspicion? A. Petechiae B. Polyuria C. Clear breath sounds D. Bradycardia

A

patient experiences a minor bleeding episode during a dental procedure. The nurse recognizes that which therapy will be beneficial? 1.Tranexamic acetate 2Fresh frozen plasma 3Desmopressin acetate 4Epsilon-aminocaproic acid

Desmopressin

Which therapy should the nurse expect to be prescribed first by the healthcare provider for a patient who is bleeding from acute disseminated intravascular coagulation (DIC)? A. Whole blood B. Fresh frozen plasma C. Aspirin D. Low molecular weight heparin

Fresh frozen plasma

A pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis? LDH

LDH

A pregnant client with a severe case of preeclampsia has just delivered a healthy preterm infant. The magnesium sulfate started prior to delivery is being continued in the postpartum period. As the postpartum nurse creates a care plan for this client, which intervention would she include? A. Slowly decreasing the magnesium sulfate dose to discontinue within 4-6 hours post delivery B. Monitoring vital signs hourly for the first 24 hours C. Informing the client that initiation of breastfeeding will have to be delayed until the third or fourth day postpartum D. Reminding the client to remain in a left​ side-lying position while in bed to maximize perfusion

Monitoring vital signs hourly for the first 24 hours

The nurse is assessing a patient diagnosed with disseminated intravascular coagulation (DIC). Which finding indicates a possible acute complication from DIC? A. Oozing of blood around the IV site B.Normal platelet levels C. A medical diagnosis of chronic DIC D. Increased platelet levels

Oozing of blood around the IV site

*The nurse reviews a patient's medical record and suspects heparin-induced thrombocytopenia (HIT). Which finding supports the nurse's conclusion? Patient has a platelet count of 100,000/µL.

Patient has a platelet count of 100,000/µL.

The nurse provides education regarding daily activities to a patient with thrombocytopenia. Which patient activity indicates understanding of the teaching? Flossing using thick tape floss 2 Shaving using an electric razor 3 Wearing flip flops to go walking 4 Brushing using a stiff-bristle toothbrush

Shaving using an electric razor

The nurse provides care for a patient with immune thrombocytopenic purpura (ITP) who has a platelet count of 90,000/mcL of blood. Which occurrence could be the reason for this condition? 1. Destruction of platelets 2. Decreased production of platelets 3. Enhanced aggregation of platelets 4. Increased consumption of platelets

2

The nurse would instruct the patient about which side effects of oral iron supplements? Select all that apply. 1 Anorexia 2 Red stools 3 Heartburn 4 Black stools 5 Constipation

345

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result? 6.1 mEq/L

6.1 mEq/L

The nurse is performing a focused assessment on the client with a diagnosis of DIC. Which assessment is included in the health history portion of the assessment? A: History of abnormal bleeding episodes B: Recent abortion (spontaneous or therapeutic) c. History of diabetes mellitus D: Presence of known malignant tumor E: Hematological disorder

ABDE

The nurse is evaluating the lab results for a client suspected of having disseminated intravascular coagulation (DIC). Which laboratory finding supports the diagnosis? (Select all that apply.) A: Increased fibrin degradation products or fibrin split products B: Elevated hemoglobin C: Shortened prothrombin​ time, thromboplastin​ time, and thrombin time D: Decreased platelet count E: The presence of fragmented red blood cells called schistocytes

ADE

A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain

B

The patient is admitted with anemia caused by blood loss and thrombocytopenia and has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should A. give the RBCs before the platelets. B. give the platelets before the RBCs. C. use local therapies to stop the bleeding. D. give the platelets and RBCs at the same time.

B

When examining the patient's laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated A. with acute bacterial infections. B. in response to allergens and parasites. C. when the spleen is removed. D. in situations that do not require phagocytosis.

B

Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient's lab results correlate with HELLP Syndrome? A. Hemoglobin 12 g/dL B. Platelets 90,000 μL C. ALT 100 IU/L D. AST 90 IU/L E. Glucose 350 mg/dL F. Abnormal RBC peripheral smear

BCDF

The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply. A) Multiparity B) Placental abruption C) Preterm labor D) Fetal death E) Gestational diabete

BD

*A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

C

The nurse assesses a client who is diagnosed with chronic disseminated intravascular coagulation (DIC). Which finding should the nurse suspect as the probable cause of the client's diagnosis? A. History of nosebleeds B. Chronic constipation C. History of a cancerous tumor D. Diminished bowel sounds

C

The nurse is caring for a patient who has undergone a splenectomy and notices that the patient's platelet count has increased. The nurse realizes that the increase is due to A. platelet response to infection. B. stimulation secondary to erythropoietin. C. the patient's inability to store platelets. D. the platelet's 120-day life cycle.

C

During the 32-week prenatal visit, a pregnant patient is diagnosed with preeclampsia and will be treated at home. The patient's current blood pressure is 142/90 mmHg. Which intervention should the nurse teach the patient to do daily to ensure that it is safe to remain at home for current treatment? A. Restrict sodium intake in the diet. B. Take blood pressure medication as directed. C. Keep exercise to a minimum. D. Monitor blood pressure.

D

The client with which condition is at the greatest risk of developing acute disseminated intravascular coagulation? A. Gunshot wound to the distal arm B. Bacterial pneumonia treated with antibiotics C. Aortic aneurysm D. Third-degree burns and septic shock

D

A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician? A. Deep tendon reflex 4+ B. Respiratory rate of 13 breaths per minute C. Urinary output of 600 mL over 12 hours D. Clonus presenting in the lower extremities E. Patient reports flushing or feeling hot

E The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: EARLY: flushing or feeling hot/warm, later on: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.

A patient that experiences prolonged bleeding is diagnosed with thrombocytopenia. The nurse expects what assessment findings? Select all that apply. Fainting Dizziness Bradycardia Hypertension Abdominal pain

Fainting Dizziness Abdominal pain

The nurse is caring for a patient newly diagnosed with acute disseminated intravascular coagulation (DIC). The main manifestation the patient is exhibiting is bleeding. Which collaborative therapy should the nurse anticipate will be administered as part of the first line of treatment? A. Heparin B. Aspirin C. Whole blood D. Platelet concentrates

Platelet concentrates

*A critically ill patient has been diagnosed with heparin-induced thrombocytopenia (HIT). What symptoms would the nurse expect? A) Gastric aspirate with positive guaiac test B) Oozing of blood around intravenous sites C) Sudden severe hypoxia and lateral chest pain D) Red blood cells in urine

Sudden severe hypoxia and lateral chest pain

A patient with a platelet count of 52,000/mm3 is diagnosed with thrombocytopenia. The nurse expects what clinical manifestations? 1 Weakness and fatigue 2 Bruising and petechiae 3 Dizziness and vomiting 4 Lightheadedness and nausea

2 Bruising and petechiae

*Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation? 1. Bradycardia. 2. Hypertension. 3. Increasing abdominal girth. 4. Petechiae

3

A patient experiences thrombocytopenia. The nurse should monitor the patient for which major complication? 1Fatigue 2Weakness 3Hemorrhage 4Abdominal pain

3

The nurse is caring for a patient with disseminated intravascular coagulation (DIC). The patient asks, "How did this happen?" Which response by the nurse is accurate? A. "DIC occurs as a complication of another illness." B. "DIC is caused by activation of the extrinsic pathway of clotting, but not by activation of the intrinsic pathway. "C. "The most common cause of DIC is trauma." D. "DIC may be caused by bacterial or viral infections, but not fungal or parasitic infections."

A

The nurse is reviewing the laboratory results for a client diagnosed with DIC. Which finding supports the diagnosis of DIC for this client? A: Prolonged prothrombin time B: Decreased fibrin split products C: High fibrinogen level D: Increased platelet count

A

The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should A. place the patient in a single room with a HEPA filtration system. B. tell staff that hand washing is not recommended when working with this patient. C. start as many intravenous lines as possible to provide potential antibiotics. D. avoid the use of antimicrobial soaps when bathing and providing perineal care.

A

Which of the following findings should lead the nurse to suspect that a client who had a cesarean birth 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider? Select all that apply. 1.Petechiae on the arm where the blood pressure was taken. 2.Heart rate of 126 bpm. 3.Abdominal incision dressing with bright red drainage. 4.Platelet count of 80,000/mm3 (80 × 109/L). 5.Urine output of 350 mL in the past 8 hours 6.Temperature of 98.4°F (36.9°C).

1234

Which laboratory result indicates thrombocytopenia? Select all that apply. 1. Hemoglobin value is 9 g/dL .2. Platelet count is 200,000/µL. 3. Bleeding time is 20 minutes .4.Hematocrit value is 42%. 5.Levels of megakaryocytes are elevated.

135

A patient with initial symptoms of immune thrombocytopenic purpura (ITP) receives corticosteroid therapy. The nurse recalls that the medication will produce which results? Select all that apply. 1- Lyse activated B cells 2- Increased CD4 T cells 3- Reduced capillary leakage 4- Depressed antibody formation 5- Increased platelet production

34

A patient with thrombocytopenia experiences a nosebleed. What is the priority nursing intervention? 1Notify the primary health care provider. 2Tap the patient's nose gently with a tissue. 3Place ice bags over the bridge of the patient's nose. 4Position the patient's head upwards and apply pressure to nostrils.

4

Which complications would the nurse monitor for in a patient who has a platelet count below 100,000/µL? 1. Leukemia 2. Leukopenia 3. Neutropenia 4. Thrombocytopenia

4

Which statement is correct regarding disseminated intravascular coagulation (DIC) following a bacterial infection? A. Endotoxin causes an inappropriate activation of the clotting cascade. B. An autoimmune disorder resulting in platelet destruction occurs. C. A decrease in the total number of white blood cells results. D. Clotting factor VIII deficiency or dysfunction specifically occurs.

A Endotoxin causes an inappropriate activation of the clotting cascade.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? A) The platelet count is 52,000/uL B) The patient is difficult yo arouse C) There are purpura on the oral mucosa D) There are large bruises on the patient's back.

B

The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which collaborative therapy should the nurse include in the client's care? (Select all that apply.) A: Monitoring client allergies B: Monitoring need for mechanical ventilation C: Monitoring for intracranial bleeding D: Monitoring for organ damage E: Monitoring intracranial pressure

BCDE

A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client? A) Increased platelet count B) Decreased liver enzymes C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine

D

A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP? a. Increased platelet count b. Elevated lipid panel c. Hemolysis d. Decreased liver enzymes

C

A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which of the following should the nurse expect the primary health care provider to prescribe? a) meperidine hydrochloride b) magnesium sulfate c) fresh-frozen platelets d) warfarin sodium

3

The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider? 1. Activated partial thromboplastin time (APTT) of 30 seconds. 2. Hemoglobin of 11.5 g/dL. 3. Urinary output of 25 mL in the past hour. 4. Platelets at 149,000/mm3.

3

The prenatal nurse has completed teaching for a pregnant patient at 28 weeks of gestation who has been diagnosed with preeclampsia. A. "I will contact your office if I have difficulty breathing or nausea and vomiting." B. "I need to notify you if I gain more than 1 pound in a week." C. "If I start to have edema in my ankles or feet, I need to call the office." D. "If my blood pressure increases at all, I should let you know."

A

Which symptom noted upon assessment of a preeclamptic patient by the nurse would indicate the need to evaluate the patient further for possible HELLP syndrome? A Hyperbilirubinemia and jaundice B Blood pressure of 168/112 mmHg C Swelling of the face, eyes, and hands D Weight gain of 4 pounds in 1 week

A

Which nursing intervention is appropriate to include in the plan of care for the client with gestational hypertension? (Select all that apply.) A Considering cultural limitations when educating the client about nutritious meal planning B Educating the client about the effect of the disease process on pregnancy C Assessing the client's blood glucose level once daily before breakfast D Educating the client about treatment alternatives for an ectopic pregnancy E Taking frequent blood pressure readings

ABE

A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply. A) Tachycardia B) Increased blood glucose level C) Decreased breath sounds D) Confusion E) Thick, tenacious bronchial secretions

ACD

A patient with preeclampsia is being managed at home. Which recommendaton should the prenatal nurse include in patient teaching concerning monitoring of the fetus? C A. Documenting the time of day of fetal movements B. Communicating the need for weekly ultrasounds C. Recording of fetal movements daily D. Noting the abdominal location of fetal movements

C

The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that a) all patients with bleeding disorders demonstrate active bleeding b) many patients have bleeding that is not obvious c) mucous membranes have a high threshold for bleeding d) capillaries in mucous membranes lie deep in the membrane

B many patients have bleeding that is not obvious.

A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment? A) Aspirin B) Warfarin (Coumadin) C) Fresh frozen plasma and platelets D) Heparin

C

DIC is a disorder in which: a. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature

C

In a preeclamptic mother, which of the following medications may be administered prior to 34 weeks gestation to enhance fetal lung maturity? a. Methylernogonovine b. Albuterol c. Beclomethasone d. Terbutaline

C

The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this client? A) Frequent ambulation B) Maintenance of skin integrity C) Preparation for radiograph procedures D) Restricting fluids

Maintenance of skin integrity

Common to both the intrinsic and the extrinsic pathway is. a) factor XII b) factor VII c) factor X d) subendothelial collagen

factor X.

A patient admitted for disseminated intravascular coagulation (DIC) reports shortness of breath, chest pain, and dark sputum when coughing. Which is the priority nursing intervention? A. Institute careful nasotracheal suctioning. B. Ambulate the patient 20 yards. C. Explain that pain medication can be given in 1 hour. D. Place the patient in high Fowler position.

Place the patient in a high Fowler position.

The nurse is reviewing the lab reports of several patients. Which report is consistent with a diagnosis of thrombocytopenia? Platelets 20,000/µL 1 Hemoglobin 13 2 Hemoglobin 16 3 Platelets 20,000/µL 4 Platelets 1,000,000/ µL

Platelets 20,000/µL

The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 159/100 mmHg B) Urinary output 40 mL/hour C) Urine protein 2+ D) Lungs clear to auscultation

Urine protein 2+

*The nurse recognizes that which medication may benefit a patient with immune thrombocytopenic purpura (ITP) by increasing the platelet production? 1 Abciximab 2 Cimetidine 3 Ganciclovir 4 eltrombopag

eltrombopag

In vivo, the primary activator of the coagulation cascade occurs via the a) intrinsic pathway b) extrinsic pathway c) common pathway d) either intrinsic or extrinsic pathway

extrinsic pathway.

A patient is admitted to the hospital for eval and treatment of thrombocytopenia. Which action is most important for the nurse to implement? monitoring the patient for headaches, vertigo, or confusion

monitoring the patient for headaches, vertigo, or confusion

Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication on standby? A. Acetylcysteine B. Calcium carbonate C. Oxytocin D. Calcium gluconate The answer is D: The antidote for Magnesium Sulfate is Calcium Gluconate. The nurse should have this on hand in case Magnesium toxicity occurs.

D

The nurse is assisting the healthcare provider with a bone marrow aspiration and biopsy on a client who has leukemia. The client also has thrombocytopenia. Upon completing the test, which intervention is a priority for the nurse? A. Label and refrigerate the specimen obtained by the physician. B. Dispose of the equipment used, and clean the area properly. C. Make certain the client understands the purpose of the test. D. Hold pressure on the wound for approximately 5 minutes.

D

A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC? A) Decreased prothrombin time B) Increased platelet count C) Decreased fibrinogen level D) Decreased partial thromboplastin time

C

The nurse is caring for a woman who has been admitted with early pregnancy-induced hypertension (PIH) that has progressed to eclampsia. The priority intervention by the nurse is to: A. check the blood pressure and fetal heart tones B. administer oxygen C. maintain a patent airway D. prepare to administer magnesium sulfate

C

The patient has a platelet count of 9,000/microliter. The nurse realizes that A. this is a normal platelet level B. spontaneous bleeding may occur. C. the patient is at great risk for fatal hemorrhage. D. this level is considered slightly low.

C

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication? A) Urinary output of 20 mL per hour B) Respiratory rate of 10 breaths/minute C) Deep tendons reflexes 2+ D) Difficulty in arousing

• Deep tendon reflexes 2+