Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
In caring for the woman with disseminated intravascular coagulation (DIC), which order should the nurse anticipate?
A. Administration of steroids
B. Administration of blood
In DIC, there is widespread clotting that can lead to depletion of clotting factors and platelets, resulting in bleeding. The priority in the care of DIC is to correct the underlying cause and to replace lost blood products to prevent hypovolemia and hemorrhage. Therefore, the nurse should anticipate an order for the administration of blood products such as packed red blood cells, fresh frozen plasma, and platelets. Administration of steroids may also be ordered to reduce inflammation and stabilize cell membranes. Restriction of intravascular fluids may be necessary to prevent further bleeding, but it is not the first priority. Invasive hemodynamic monitoring may be used to assess the client's fluid and electrolyte status, but it is not typically the first intervention.
C. Restriction of intravascular fluids
D. Preparation of the client for invasive hemodynamic monitoring
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Full Explanation
In DIC, there is widespread clotting that can lead to depletion of clotting factors and platelets, resulting in bleeding. The priority in the care of DIC is to correct the underlying cause and to replace lost blood products to prevent hypovolemia and hemorrhage. Therefore, the nurse should anticipate an order for the administration of blood products such as packed red blood cells, fresh frozen plasma, and platelets. Administration of steroids may also be ordered to reduce inflammation and stabilize cell membranes. Restriction of intravascular fluids may be necessary to prevent further bleeding, but it is not the first priority. Invasive hemodynamic monitoring may be used to assess the client's fluid and electrolyte status, but it is not typically the first intervention.
Similar Questions
The nurse is caring for a 30-week gestation client who was loaded on a magnesium sulfate infusion one hour ago for preterm labor. Which of the following assessment findings would warrant the infusion to be discontinued immediately?
A. Blood pressure of 138/88.
B. Urinary output of 40 ml/hr.
C. Respiratory rate of 10 breaths/minute.
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
D. Patellar reflex of +2.
Full Explanation
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
Educating a client about starting nifedipine (Procardia) for preterm labor prevention, the nurse knows that her educational plan for this client should include which of the following?
A. Your respiratory rate may slow down, so make sure to monitor your breathing rate!
B. You will most likely be hospitalized until delivery while on your medication
C. You should try to get up slowly and drink plenty of fluids
Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.
D. You will stop this medication at 28 weeks.
Full Explanation
Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.
A woman in preterm labor at 30 weeks of gestation receives two 12 mg doses of betamethasone (Celestane) intramuscularly. The purpose of this pharmacologic treatment is to:
A. Reduce maternal and fetal tachycardia associated with terbutaline administration.
B. Suppress uterine contractions.
C. Stimulate fetal surfactant production.
Betamethasone is a corticosteroid that enhances fetal lung maturity, which can help reduce the risk of respiratory distress syndrome and other complications in preterm infants. It does not reduce maternal and fetal tachycardia associated with terbutaline administration, suppress uterine contractions, or maintain maternal respiratory effort and ventilation during magnesium sulfate therapy.
D. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
Full Explanation
Betamethasone is a corticosteroid that enhances fetal lung maturity, which can help reduce the risk of respiratory distress syndrome and other complications in preterm infants. It does not reduce maternal and fetal tachycardia associated with terbutaline administration, suppress uterine contractions, or maintain maternal respiratory effort and ventilation during magnesium sulfate therapy.