A client with multiple injuries to the head, chest, and abdomen has had their airway stabilized and is breathing on their own. Which symptom would lead the nurse to suspect internal hemorrhaging even when the nurse does not see any bleeding?

Increased sweating

Increased redness at the site

Increased abdominal distention

Increased blood pressure

Answer and Explanation

The Correct Answer is C

A. Increased sweating: This is incorrect. Increased sweating is not typically indicative of internal hemorrhaging. It can be associated with various conditions but is not a specific sign of internal bleeding.
B. Increased redness at the site: This is incorrect. Increased redness would more likely be associated with localized infection or inflammation rather than internal hemorrhaging.
C. Increased abdominal distention: This is correct. Increased abdominal distention can be a sign of internal hemorrhaging, particularly if blood accumulates in the abdominal cavity (hemoperitoneum), leading to abdominal swelling and discomfort.
D. Increased blood pressure: This is incorrect. Internal hemorrhaging often leads to hypotension rather than increased blood pressure, as blood volume decreases and the body attempts to compensate.

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Correct Answer is A

Explanation

A. "I can detect the presence of carbon monoxide by a metallic odor." This is incorrect. Carbon monoxide is odorless, colorless, and tasteless, making it undetectable by smell.
B. "A high concentration of carbon monoxide can cause unconsciousness." This is correct. High levels of carbon monoxide can lead to serious symptoms including loss of consciousness.
C. "Breathing in carbon monoxide can cause headaches and nausea." This is correct. Symptoms of carbon monoxide poisoning include headaches, nausea, and dizziness.
D. "Leaky gas or oil furnaces can cause carbon monoxide poisoning." This is correct. Faulty or leaky heating systems can be a source of carbon monoxide exposure.

A. Ensure the client's intake is greater than their output. B. Monitor the client's urine output every eight hours. C. Remind the client he might feel a constant urge to void. D. Assess for manifestations of fluid volume deficiency.

Correct Answer is C

Explanation

A. Ensure the client's intake is greater than their output: This is incorrect. In continuous bladder irrigation, the output may exceed the intake because the irrigation fluid is used to flush the bladder. The focus should be on ensuring proper drainage and monitoring for clots or obstruction rather than ensuring intake exceeds output.
B. Monitor the client's urine output every eight hours: This is incorrect. Following a transurethral resection of the prostate with continuous bladder irrigation, urine output should be monitored more frequently to ensure the irrigation system is functioning properly and to assess for signs of bleeding or obstruction.
C. Remind the client he might feel a constant urge to void: This is correct. It is common for clients to experience a constant urge to void due to bladder irritation and the presence of the catheter.
D. Assess for manifestations of fluid volume deficiency: This is incorrect. The primary concern with continuous bladder irrigation is monitoring for signs of bleeding or obstruction rather than fluid volume deficiency. Fluid balance is monitored based on intake and output, but deficiency is less likely in this context.

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A client with multiple injuries to the head, chest, and abdomen has had their airway stabilized and is breathing on their own. Which symptom would lead the nurse to suspect internal hemorrhaging even when the nurse does not see any bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client requires further education?

Correct Answer is A

Explanation

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

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