ATI Book - Med Surg 2 Chapter 42

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small‑vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

C. Cyanotic nail beds Cyanotic nail beds indicate microvascular clotting is occurring and should be immediately reported to avoid ischemic loss of the fingers or toes.

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

C. Epistaxis Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC.

A nurse is teaching a newly licensed nurse about heparin‑induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching? A. Warfarin therapy for atrial fibrillation B. Placental abruption C. Systemic lupus erythematosus D. Heparin therapy for deep‑vein thrombosis

D. Heparin therapy for deep‑vein thrombosis The client who is receiving heparin therapy for longer than 1 week is at increased risk for the development of HIT.

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. Heparin Heparin can be administered to decrease the formation of microclots, which deplete clotting factors.

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000/mm3 B. Fibrinogen levels 57 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D‑dimer 0.03 mcg/mL E. Sedimentation rate 38 mm/hr

A. Platelets 100,000/mm3 B. Fibrinogen levels 57 mg/dL In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage.