MCA III Final Exam - Practice Questions And
Answers (Answered)
Which client would be most at risk for developing disseminated intravascular
coagulation (DIC)?
1. A 35 year old pregnant client with placenta previa
2. A 42 year old client with a pulmonary embolus
3. A 60 year old client receiving hemodialyasis 3 days a week
4. A 78 year old client with septicemia
4. A 78 year old client with septicemia
DIC is a clinical syndrome that develops as a complication of a wide variety of other
disorders, with sepsis being the most common cause of DIC
The client is admitted with full-thickness burns may be developing DIC. Which
signs/symptoms would support the diagnosis of DIC?
1. Oozing blood from the IV catheter site
2. Sudden onset of chest pain and frothy sputum
3. Foul smelling, concentrated urine
4. A reddened, inflamed central line catheter site
1. Oozing blood from the IV catheter site
Signs and symptoms of DIC result from clotting and bleeding, ranging from oozing blood
to bleeding from every body orifice and into the tissues
Which lab result would the nurse expect in the client diagnosed with DIC?
1. A decreased prothrombin time (PT)
2. A low fibrinogen level
3. An increased platelet count
4. An increased white blood cell count
2. A low fibrinogen level
Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding
increases.
Which collaborative treatment would the nurse anticipate in the client diagnosed
with DIC?
1. Administer oral anticoagulants
2. Prepare for plasmapheresis
3. Administer fresh frozen plasma
4. Calculate the intake and output
3. Administer fresh frozen plasma
Fresh frozen plasma and platelet concentrates are administered to restore clotting
factors and platelets
The nurse writes a diagnosis of "potential for fluid volume deficit related to
bleeding" for a client diagnosed with DIC. Which would be an appropriate goal?
1. The client's clot formations will resolve in two days
2. The saturation of the client's dressings will be documented
3. The client will use lemon-glycerin swabs for oral care
4. The client's urine output will be > 30 mL per hour
4. The client's urine output will be > 30 mL per hour
,The problem is addressing the potential for hemorrhage, and a urine output of greater
than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not
in shock.
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. Infuse normal saline 500 mL over 30 minutes.
The patient's blood pressure indicates hypovolemia caused by blood loss and should be
addressed immediately to improve perfusion to vital organs.
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 other venipunctures.
b. Apply dressings to the sites.
c. Notify the health care provider.
d. Give prescribed proton-pump inhibitors.
c. Notify the health care provider.
The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated
intravascular coagulation (DIC) may have developed, which will require collaborative
actions such as diagnostic testing, blood product administration, and heparin
administration. The other actions are also appropriate, but the most important action
should be to notify the health care provider so that DIC treatment can be initiated rapidly
A patient's family member asks the nurse what caused the patient to develop
disseminated intravascular coagulation (DIC). The nurse tells the family member
that DIC
a. is caused by an abnormal activation of clotting.
b. occurs when the immune system attacks platelets.
c. is a complication of cancer chemotherapy.
d. is caused when hemolytic processes destroy erythrocytes.
a. is caused by an abnormal activation of clotting.
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. a disease process stimulates coagulation processes with resultant thrombosis,
as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage
The patient with leukemia has acute disseminated intravascular coagulation (DIC)
and is bleeding. What diagnostic findings should the nurse expect to find?
,a. elevated D-dimers
b. elevated fibrinogen
c. reduced prothrombin time (PT)
d. reduced fibrin degradation products (FDPs)
a. elevated D-dimers
After the diagnosis of disseminated intravascular coagulation (DIC), what is the
first priority of collaborative care?
a. administer heparin.
b. administer whole blood.
c. treat the causative problem.
d. administer fresh frozen plasma.
c. treat the causative problem.
A client is admitted to the Intensive Care Unit with disseminated intravascular
coagulation. What will the nurse most likely assess in this client? (SATA)
A) Tachycardia
B) Increased blood glucose level
C) Decreased breath sounds
D) Confusion
E) Thick, tenacious bronchial secretions
A) Tachycardia
C) Decreased breath sounds
D) Confusion
Clinical manifestations of disseminated intravascular coagulation include decreased
breath sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial
secretions are not associated with this health problem.
The nurse is evaluating care provided to a client with disseminated intravascular
coagulation. Which observation indicates care has been successful for this
client?
A) Heart rate 110 beats per minute
B) Oxygen saturation level 86%
C) Urine output 20 cc per hour
D) No evidence of bleeding
D) No evidence of bleeding
Care provided to a client with disseminated intravascular coagulation is successful
when there is no further bleeding. Oxygen saturation of 86% is evidence that treatment
is needed. Heart rate of 110 beats per minute is evidence that treatment is needed.
Urine output of 20 cc per hour is below normal limits and would indicate the need for
further treatment.
A client diagnosed with disseminated intravascular coagulation (DIC) is currently
bleeding through the gastrointestinal tract. What will the nurse expect to provide
for the client?
A) Aspirin
B) Coumadin
C) Fresh frozen plasma and platelets
D) Heparin
C) Fresh frozen plasma and platelets
, Explanation: C) When bleeding is the major manifestation of DIC, fresh frozen plasma
and platelet concentrates are given to restore clotting factors and platelets. Heparin may
be administered if bleeding is not controlled by plasma and platelets and if the client has
manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the
treatment of DIC.
A client has disseminated intravascular coagulation (DIC). Which clinical
manifestation should the nurse expect to observe? (SATA)
A. Clotting
B. Hypertension
C. Bleeding
D. Joint pain
E. Petechiae
A. Clotting
C. Bleeding
E. Petechiae
Family members of a patient who has a traumatic brain injury ask the nurse about
the purpose of the ventriculostomy system being used for intracranial pressure
monitoring. Which response by the nurse is best for this situation?
a. "This type of monitoring system is complex and it is managed by skilled staff."
b. "The monitoring system helps show whether blood flow to the brain is adequate."
c. "The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure."
d. "This monitoring system has multiple benefits including facilitation of cerebrospinal
fluid drainage."
b. "The monitoring system helps show whether blood flow to the brain is
adequate."
Short and simple explanations should be given initially to patients and family members.
The other explanations are either too complicated to be easily understood or may
increase the family members' anxiety.
Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm
Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital
signs, if taken 1 hour later, will be of most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad. These findings indicate that the intracranial pressure
(ICP) has increased, and brain herniation may be imminent unless immediate action is
Answers (Answered)
Which client would be most at risk for developing disseminated intravascular
coagulation (DIC)?
1. A 35 year old pregnant client with placenta previa
2. A 42 year old client with a pulmonary embolus
3. A 60 year old client receiving hemodialyasis 3 days a week
4. A 78 year old client with septicemia
4. A 78 year old client with septicemia
DIC is a clinical syndrome that develops as a complication of a wide variety of other
disorders, with sepsis being the most common cause of DIC
The client is admitted with full-thickness burns may be developing DIC. Which
signs/symptoms would support the diagnosis of DIC?
1. Oozing blood from the IV catheter site
2. Sudden onset of chest pain and frothy sputum
3. Foul smelling, concentrated urine
4. A reddened, inflamed central line catheter site
1. Oozing blood from the IV catheter site
Signs and symptoms of DIC result from clotting and bleeding, ranging from oozing blood
to bleeding from every body orifice and into the tissues
Which lab result would the nurse expect in the client diagnosed with DIC?
1. A decreased prothrombin time (PT)
2. A low fibrinogen level
3. An increased platelet count
4. An increased white blood cell count
2. A low fibrinogen level
Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding
increases.
Which collaborative treatment would the nurse anticipate in the client diagnosed
with DIC?
1. Administer oral anticoagulants
2. Prepare for plasmapheresis
3. Administer fresh frozen plasma
4. Calculate the intake and output
3. Administer fresh frozen plasma
Fresh frozen plasma and platelet concentrates are administered to restore clotting
factors and platelets
The nurse writes a diagnosis of "potential for fluid volume deficit related to
bleeding" for a client diagnosed with DIC. Which would be an appropriate goal?
1. The client's clot formations will resolve in two days
2. The saturation of the client's dressings will be documented
3. The client will use lemon-glycerin swabs for oral care
4. The client's urine output will be > 30 mL per hour
4. The client's urine output will be > 30 mL per hour
,The problem is addressing the potential for hemorrhage, and a urine output of greater
than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not
in shock.
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. Infuse normal saline 500 mL over 30 minutes.
The patient's blood pressure indicates hypovolemia caused by blood loss and should be
addressed immediately to improve perfusion to vital organs.
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 other venipunctures.
b. Apply dressings to the sites.
c. Notify the health care provider.
d. Give prescribed proton-pump inhibitors.
c. Notify the health care provider.
The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated
intravascular coagulation (DIC) may have developed, which will require collaborative
actions such as diagnostic testing, blood product administration, and heparin
administration. The other actions are also appropriate, but the most important action
should be to notify the health care provider so that DIC treatment can be initiated rapidly
A patient's family member asks the nurse what caused the patient to develop
disseminated intravascular coagulation (DIC). The nurse tells the family member
that DIC
a. is caused by an abnormal activation of clotting.
b. occurs when the immune system attacks platelets.
c. is a complication of cancer chemotherapy.
d. is caused when hemolytic processes destroy erythrocytes.
a. is caused by an abnormal activation of clotting.
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. a disease process stimulates coagulation processes with resultant thrombosis,
as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage
The patient with leukemia has acute disseminated intravascular coagulation (DIC)
and is bleeding. What diagnostic findings should the nurse expect to find?
,a. elevated D-dimers
b. elevated fibrinogen
c. reduced prothrombin time (PT)
d. reduced fibrin degradation products (FDPs)
a. elevated D-dimers
After the diagnosis of disseminated intravascular coagulation (DIC), what is the
first priority of collaborative care?
a. administer heparin.
b. administer whole blood.
c. treat the causative problem.
d. administer fresh frozen plasma.
c. treat the causative problem.
A client is admitted to the Intensive Care Unit with disseminated intravascular
coagulation. What will the nurse most likely assess in this client? (SATA)
A) Tachycardia
B) Increased blood glucose level
C) Decreased breath sounds
D) Confusion
E) Thick, tenacious bronchial secretions
A) Tachycardia
C) Decreased breath sounds
D) Confusion
Clinical manifestations of disseminated intravascular coagulation include decreased
breath sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial
secretions are not associated with this health problem.
The nurse is evaluating care provided to a client with disseminated intravascular
coagulation. Which observation indicates care has been successful for this
client?
A) Heart rate 110 beats per minute
B) Oxygen saturation level 86%
C) Urine output 20 cc per hour
D) No evidence of bleeding
D) No evidence of bleeding
Care provided to a client with disseminated intravascular coagulation is successful
when there is no further bleeding. Oxygen saturation of 86% is evidence that treatment
is needed. Heart rate of 110 beats per minute is evidence that treatment is needed.
Urine output of 20 cc per hour is below normal limits and would indicate the need for
further treatment.
A client diagnosed with disseminated intravascular coagulation (DIC) is currently
bleeding through the gastrointestinal tract. What will the nurse expect to provide
for the client?
A) Aspirin
B) Coumadin
C) Fresh frozen plasma and platelets
D) Heparin
C) Fresh frozen plasma and platelets
, Explanation: C) When bleeding is the major manifestation of DIC, fresh frozen plasma
and platelet concentrates are given to restore clotting factors and platelets. Heparin may
be administered if bleeding is not controlled by plasma and platelets and if the client has
manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the
treatment of DIC.
A client has disseminated intravascular coagulation (DIC). Which clinical
manifestation should the nurse expect to observe? (SATA)
A. Clotting
B. Hypertension
C. Bleeding
D. Joint pain
E. Petechiae
A. Clotting
C. Bleeding
E. Petechiae
Family members of a patient who has a traumatic brain injury ask the nurse about
the purpose of the ventriculostomy system being used for intracranial pressure
monitoring. Which response by the nurse is best for this situation?
a. "This type of monitoring system is complex and it is managed by skilled staff."
b. "The monitoring system helps show whether blood flow to the brain is adequate."
c. "The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure."
d. "This monitoring system has multiple benefits including facilitation of cerebrospinal
fluid drainage."
b. "The monitoring system helps show whether blood flow to the brain is
adequate."
Short and simple explanations should be given initially to patients and family members.
The other explanations are either too complicated to be easily understood or may
increase the family members' anxiety.
Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm
Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital
signs, if taken 1 hour later, will be of most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad. These findings indicate that the intracranial pressure
(ICP) has increased, and brain herniation may be imminent unless immediate action is
