The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first?

Question

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Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. disseminated intravascular coagulation Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death. petechiae (Option A) Stool leaking from an ileostomy bag is not a priority. (Option B) It is common for clients with chronic obstructive pulmonary disease to have diminished breath sounds; the goal SpO₂ level in this population is generally ≥90%. (Option C) Although missing warfarin can increase the risk of clotting, most clients will usually have a therapeutic INR for 1-2 days. This is not a priority over the DIC client. Educational objective: Disseminated intravascular coagulation (DIC) results from abnormal activation of clotting cascade followed by consumption of clotting factors and platelets; this quickly leads to life-threatening external and internal bleeding. Any signs of DIC should be assessed immediately as emergent replacement of clotting factors, blood, and platelets is needed to save the client.

The Nurse Is Caring for Clients on a Busy Medical-Surgical