The nurse learns that a client with sepsis has developed disseminated intravascular coagulation (DIC). The nurse should plan to:
1. Check peripheral pulses and capillary refill frequently.
2. Restrict fluid intake to prevent vascular fluid overload.
3. Keep the client in a low Fowler's position to promote venous return.
4. Encourage frequent ambulation in the hallway.
Answer: 1
1. Identification of impaired circulation will alert the nurse to impaired tissue perfusion secondary to microvascular blood clotting.
2. Restricting fluids can enhance blood clotting.
3. Semi-Fowler's position improves lung expansion and oxygenation.
4. Bedrest should be maintained to decrease oxygen demand.
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