The nurse learns a client with sepsis has developed disseminated intravascular coagulation (DIC). The nurse should plan to:
A)
encourage frequent ambulation in the hallway.
B)
check peripheral pulses and capillary refill frequently.
C)
keep client in a low-Fowler's position to promote venous return.
D)
restrict fluid intake to prevent vascular fluid overload.
B
Explanation:
A)
Identification of impaired circulation will alert the nurse to impaired tissue perfusion secondary to microvascular blood clotting. Bed rest should be maintained to decrease oxygen demand. Semi-Fowler's position improves lung expansion and oxygenation. Fluids should not be restricted.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
B)
Identification of impaired circulation will alert the nurse to impaired tissue perfusion secondary to microvascular blood clotting. Bed rest should be maintained to decrease oxygen demand. Semi-Fowler's position improves lung expansion and oxygenation. Fluids should not be restricted.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
C)
Identification of impaired circulation will alert the nurse to impaired tissue perfusion secondary to microvascular blood clotting. Bed rest should be maintained to decrease oxygen demand. Semi-Fowler's position improves lung expansion and oxygenation. Fluids should not be restricted.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
D)
Identification of impaired circulation will alert the nurse to impaired tissue perfusion secondary to microvascular blood clotting. Bed rest should be maintained to decrease oxygen demand. Semi-Fowler's position improves lung expansion and oxygenation. Fluids should not be restricted.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
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