Nokea
A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
- A. Hypotension
- B. Diaphoresis
- C. Bradycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypotension and tachypnea are signs of hemorrhage due to decreased blood volume and compensatory increased respiratory rate. Diaphoresis may occur but is less specific, while bradycardia and diarrhea are not typical.
You may also like to solve these questions
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. A piece of healthy skin will be removed from an unburned area and grafted over the burned area.
- B. Large incisions will be made in the eschar to improve circulation.
- C. The procedure involves placing the client into a shower and removing the dead tissue.
- D. Dead tour will be non-surgically removed.
Correct Answer: B
Rationale: An escharotomy involves incisions through the eschar to relieve pressure and improve blood flow, preventing complications like compartment syndrome. Other options describe different procedures.
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
- A. Hemolytic
- B. Allergic
- C. Febrile
- D. Bacterial
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
- A. "I need something for the pain in my eye. I can't stand it."
- B. "It's hard to see with a patch on one eye. I'm afraid of falling"
- C. "My eye really itches, but I'm trying not to rub it."
- D. "The bright light in this room is really bothering me."
Correct Answer: A
Rationale: Severe pain after cataract surgery is unusual and could indicate complications like increased intraocular pressure or infection, requiring immediate reporting. Other comments reflect common post-surgical experiences.
A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?
- A. instruct the client to dig their heels into the bed to push themselves upwards.
- B. Assist the client with a trapeze to raise their body while staff assists with repositioning
- C. Have two to three staff members pull the client up in bed when needed.
- D. Elevate the head of the bed 90° for bedridden clients.
Correct Answer: B
Rationale: Using a trapeze reduces friction and shear forces during repositioning, preventing skin injuries. Other options increase friction or shear risks.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.