A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?

Tachycardia

Flushed skin

Polyuria

Firm fundus

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.

Choice B rationale:

Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.

Choice C rationale:

Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.

Choice D rationale:

A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.

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Correct Answer is D

Explanation

Choice A rationale:

Identifying whether incivility is present is important, but it's more proactive to initially focus on promoting a safe environment.

Choice B rationale:

Modeling professional behavior is essential, but addressing incivility requires a comprehensive approach that involves the entire team.

Choice C rationale:

Developing a zero-tolerance policy is important, but it should come after promoting a safe and respectful environment.

Choice D rationale:

Creating an emotionally safe environment fosters open communication and helps prevent incivility from occurring in the first place.

A. Provide rest breaks between nursing care activities. B. Notify the provider of a systolic BP higher than 180 mm Hg. C. Administer aspirin 650 mg every 6 hr for a headache. D. Keep the client's head in a midline neutral position. E. Monitor the client's vital signs every 4 hr

Correct Answer is ["A","B","D","E"]

Explanation

A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.

B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.

C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.

D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.

E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.

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A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is developing a protocol to address incivility in the nursing unit. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","D","E"]

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