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    Nurs 547 Med Surg Proctored Exam(Examplify)
    Select All That Apply

    The nurse is caring for a patient who is being treated for disseminated intravascular coagulation (DIC). What are the top three highest priorities that the nurse includes in the plan of care for this patient? Select the three highest priorities.

    Explanation & Rationale

    A. Monitor respiratory status: DIC can lead to microvascular thrombosis in the lungs, causing impaired gas exchange, hypoxia, or pulmonary edema. Continuous assessment of respiratory function, oxygen saturation, and signs of distress is critical to detect early respiratory compromise and prevent progression to respiratory failure. B. Perform neurological assessments every 15 minutes: Frequent neurological checks are important if there is a concern for intracranial bleeding, but for most patients with DIC, every 15 minutes may be excessive unless acute neurologic changes occur. Standard neurological monitoring remains important but is secondary to respiratory compromise and active bleeding. C. Monitor intake and output: Monitoring fluid balance is important in DIC because patients may develop shock or renal impairment; however, this is supportive care and does not take priority over interventions that address life-threatening bleeding or oxygenation issues. D. Frequent vital sign assessments: Vital signs provide critical information on perfusion, hemodynamic stability, and early signs of shock. Tachycardia, hypotension, or fever can indicate worsening DIC or secondary complications, making frequent monitoring essential to guide timely interventions. E. Monitor for bleeding: DIC causes widespread consumption of clotting factors, predisposing patients to spontaneous or procedure-related hemorrhage. Vigilant monitoring for signs of bleeding (mucosal, gastrointestinal, intravenous sites) is a top priority to initiate rapid interventions and prevent life-threatening hemorrhage.

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