NURS 482: Nursing Care of the Complex
Clients II Exam Questions Answers
The nurse is caring for a client with Disseminated Intravascular Coagulopathy (DIC). What is the
rationale to monitor for symptoms of thrombus formation AND to implement bleeding
precautions? - ANS Once clotting factors are depleted, the client is high risk for
hemorrhage
Rationale: DIC first starts with triggering of widespread release of clotting factors which initially
cause thromus formation, after all the clotting factors are utilized, levels are significantly low
resulting in hemmorhage. LeMone pp. 1057
Which manifestation is the most common sign of a systemic inflammatory response? - ANS
fever
Rationale: Fever is the most common sign of a systemic inflammatory response. Swelling and
redness are local responses to inflammation and bradycardia is not a sign of inflammation.
The nurse is caring for a client with Disseminated Intravascular Coagulopathy (DIC). What
should she include in the plan of care? - ANS Perform frequent assessment of mental
status
Rationale: Clients with DIC are at risk for bleeding and thrombus. Assessing mental status is
important as DIC can cause brain clots or hemorrhage. Only small gauge needles should be
used for venapunctures. A catheter is not indicated and could cause bleeding. Legs could be
elevated but not with a pillow under the knees.
Which statement is true about sepsis? - ANS Sepsis is the leading cause of death in
noncoronary intensive care patients
Rationale: Incidents of sepsis is rising in the United States despite the availability of antibiotics..
The population at the greatest risk for sepsis is older adults. Sepsis is the leading cause of
death in noncoronary intensive care patients. Although viral infections are increasing, the most
common cause of sepsis is still bacterial infection.
Which is the primary nursing diagnosis for a client with multiple organ dysfunction syndrome
(MODS)? - ANS Decreased tissue perfusion
, Rationale: The primary cause of MODs is decreased tissue perfusion that results in multiple
organ dysfunction.
Which is the preferred antiseptic for prepping a client for central line insertion for maximum
benefit of infection prevention? - ANS Chlorhexidine
Rationale: Chlorhexidine skin antiseptic has been shown to provide better skin asepsis in
preparing for line insertion.
Hospital acquired infections (HAI) are a leading cause of sepsis in critically ill clients. All of the
following are common origins of HAIs EXCEPT: - ANS heart
Hospital acquired infections (HAI) are a leading cause of sepsis in critically ill clients and usually
original in the bloodstream through catheter and central lines, UTIs and pneumonia.
Which diagnostic would the nurse expect to be ordered to evaluate the nutritional status of a
client with sepsis? - ANS prealbumin
Rationale: Maintaining nutritional status is critical to managing sepsis, especially protein, vitamin
C and iron. Albumin and prealbumin levels will help determine protein requirements.
Which manifestation could indicate the client is developing sepsis? Select All that Apply - ANS
-tachycardia
-confusion
-nausea
Rationale: S/S of sepsis include tachycardia, tachypnea, fever, flushed skin, nausea,
hypotension and confusion.
A client on an acute care unit is diagnosed with bacterial pneumonia. The nurse knows that
which of the following would characterize the pneumonia as hospital acquired (HAP)? - ANS
Client's pneumonia developed 72 hours after admission
Rationale: HAP is characterized by the development of pneumonia 48 hours or more after
admission to a hospital or care unit.
A client is admitted to the ICU after a motor vehicle accident resulting in shock. All of the
following are indicators of the body's compensatory mechanisms in response to shock EXCEPT:
- ANS increased urine output
Rationale: When the body goes into a shock state the sympathetic nervous system is activated
causing increased HR, peripheral vasocontriction, and increased respirations. Urine output is
decreased due to vasocontriction and decreased perfusion to the kidneys.
Clients II Exam Questions Answers
The nurse is caring for a client with Disseminated Intravascular Coagulopathy (DIC). What is the
rationale to monitor for symptoms of thrombus formation AND to implement bleeding
precautions? - ANS Once clotting factors are depleted, the client is high risk for
hemorrhage
Rationale: DIC first starts with triggering of widespread release of clotting factors which initially
cause thromus formation, after all the clotting factors are utilized, levels are significantly low
resulting in hemmorhage. LeMone pp. 1057
Which manifestation is the most common sign of a systemic inflammatory response? - ANS
fever
Rationale: Fever is the most common sign of a systemic inflammatory response. Swelling and
redness are local responses to inflammation and bradycardia is not a sign of inflammation.
The nurse is caring for a client with Disseminated Intravascular Coagulopathy (DIC). What
should she include in the plan of care? - ANS Perform frequent assessment of mental
status
Rationale: Clients with DIC are at risk for bleeding and thrombus. Assessing mental status is
important as DIC can cause brain clots or hemorrhage. Only small gauge needles should be
used for venapunctures. A catheter is not indicated and could cause bleeding. Legs could be
elevated but not with a pillow under the knees.
Which statement is true about sepsis? - ANS Sepsis is the leading cause of death in
noncoronary intensive care patients
Rationale: Incidents of sepsis is rising in the United States despite the availability of antibiotics..
The population at the greatest risk for sepsis is older adults. Sepsis is the leading cause of
death in noncoronary intensive care patients. Although viral infections are increasing, the most
common cause of sepsis is still bacterial infection.
Which is the primary nursing diagnosis for a client with multiple organ dysfunction syndrome
(MODS)? - ANS Decreased tissue perfusion
, Rationale: The primary cause of MODs is decreased tissue perfusion that results in multiple
organ dysfunction.
Which is the preferred antiseptic for prepping a client for central line insertion for maximum
benefit of infection prevention? - ANS Chlorhexidine
Rationale: Chlorhexidine skin antiseptic has been shown to provide better skin asepsis in
preparing for line insertion.
Hospital acquired infections (HAI) are a leading cause of sepsis in critically ill clients. All of the
following are common origins of HAIs EXCEPT: - ANS heart
Hospital acquired infections (HAI) are a leading cause of sepsis in critically ill clients and usually
original in the bloodstream through catheter and central lines, UTIs and pneumonia.
Which diagnostic would the nurse expect to be ordered to evaluate the nutritional status of a
client with sepsis? - ANS prealbumin
Rationale: Maintaining nutritional status is critical to managing sepsis, especially protein, vitamin
C and iron. Albumin and prealbumin levels will help determine protein requirements.
Which manifestation could indicate the client is developing sepsis? Select All that Apply - ANS
-tachycardia
-confusion
-nausea
Rationale: S/S of sepsis include tachycardia, tachypnea, fever, flushed skin, nausea,
hypotension and confusion.
A client on an acute care unit is diagnosed with bacterial pneumonia. The nurse knows that
which of the following would characterize the pneumonia as hospital acquired (HAP)? - ANS
Client's pneumonia developed 72 hours after admission
Rationale: HAP is characterized by the development of pneumonia 48 hours or more after
admission to a hospital or care unit.
A client is admitted to the ICU after a motor vehicle accident resulting in shock. All of the
following are indicators of the body's compensatory mechanisms in response to shock EXCEPT:
- ANS increased urine output
Rationale: When the body goes into a shock state the sympathetic nervous system is activated
causing increased HR, peripheral vasocontriction, and increased respirations. Urine output is
decreased due to vasocontriction and decreased perfusion to the kidneys.
