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An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC?
- A. A patient with extensive burns
- B. A patient who has a diagnosis of acute respiratory distress syndrome
- C. A patient who suffered multiple trauma in a workplace accident
- D. A patient who is being treated for septic shock
Correct Answer: D
Rationale: Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically identified as a cause.
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A patient is admitted to the diagnosis of pernicious anemia. The nurse should prepare to administer which of the following medications?
- A. Folic acid
- B. Vitamin B12
- C. Lactulose
- D. Magnesium sulfate
Correct Answer: B
Rationale: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia.
A patient's low prothrombin time (PT) was attributed to a vitamin K deficiency and the patient's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize?
- A. The need for adequate nutrition
- B. The need to avoid NSAIDs
- C. The need for constant access to factor concentrate
- D. The need for meticulous hygiene
Correct Answer: A
Rationale: Vitamin K deficiency is often the result of a nutritional deficit. NSAIDs do not influence vitamin K synthesis and clotting factors are not necessary to treat or prevent a vitamin K deficiency. Hygiene is not related to the onset or prevention of vitamin K deficiency.
A nurse is caring for a patient who has sickle cell anemia and the nurses assessment reveals the possibility of substance abuse. What is the nurses most appropriate action?
- A. Encourage the patient to rely on complementary and alternative therapies.
- B. Encourage the patient to seek care from a single provider for pain relief.
- C. Teach the patient to accept chronic pain as an inevitable aspect of the disease.
- D. Limit the reporting of emergency department visits to the primary health care provider.
Correct Answer: B
Rationale: The patient should be encouraged to use a single primary health care provider to address health care concerns. Emergency department visits should be reported to the primary health care provider to achieve optimal management of the disease. It would be inappropriate to teach the patient to simply accept his or her pain. Complementary therapies are usually insufficient to fully address pain in sickle cell disease.
The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend?
- A. Using prophylactic antibiotics and performing meticulous hygiene
- B. Maximizing physical activity and taking OTC iron supplements
- C. Limiting psychosocial stress and eating a high-protein diet
- D. Avoiding cold temperatures and ensuring sufficient hydration
Correct Answer: D
Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.
A patient is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5°F and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action?
- A. Apply supplementary oxygen by nasal cannula.
- B. Administer bronchodilators by nebulizer.
- C. Liaise with the respiratory therapist and consider high-flow oxygen.
- D. Inform the primary care provider that the patient may have an infection.
Correct Answer: D
Rationale: Patients with sickle cell disease are highly susceptible to infection; thus any early signs of infection should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated.