A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

Bradycardia

Increased blood pressure

Warm, flushed skin

Decreased urine output

Answer and Explanation

The Correct Answer is B

A) Incorrect. Bradycardia is not typically an early sign of compensatory response to hypovolemia. The body often responds to hypovolemia with an increased heart rate (tachycardia).

B) Correct. In the early stages of hypovolemia, the body may attempt to compensate by increasing blood pressure to maintain perfusion to vital organs.

C) Incorrect. Warm, flushed skin may be present in the initial stages of hypovolemia, but it is not necessarily an early sign of compensatory response.

D) Incorrect. Decreased urine output is a later sign of hypovolemia when the body's compensatory mechanisms are no longer effective in maintaining blood flow to the kidneys.

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Correct Answer is B

Explanation

A) Incorrect. Checking the client's blood pressure is important but not the most critical action before starting a blood transfusion.

B) Correct. The most crucial step before administering any intervention, including a blood transfusion, is to verify the client's identification using two identifiers (e.g., name and date of birth or medical record number) to ensure the right blood is given to the right client.

C) Incorrect. While assessing the client's oxygen saturation is important, it is not the priority before starting a blood transfusion.

D) Incorrect. Obtaining consent for the blood transfusion is essential, but verifying the client's identification is more critical before administering the transfusion.

A. The client has a history of hypertension. B. The client has been taking anticoagulant medication. C. The client is a regular blood donor. D. The client has a balanced diet.

Correct Answer is B

Explanation

A) Incorrect. While hypertension can be a risk factor for cardiovascular issues, it is not directly associated with an increased risk of hemorrhage.

B) Correct. Anticoagulant medication can interfere with the body's clotting mechanisms, making the client more susceptible to bleeding and hemorrhage.

C) Incorrect. Being a regular blood donor does not inherently increase the risk of hemorrhage unless the client donates too frequently, leading to anemia.

D) Incorrect. Having a balanced diet is essential for overall health, but it is not a specific risk factor for hemorrhage.

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A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

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Naxlex Comprehensive Predictor Exams

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Explanation

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