A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

restlessness, rising pulse, and falling blood pressure.

lethargy, falling pulse, and rising blood pressure.

headache, rising pulse, and falling blood pressure.

restlessness, falling pulse, and rising blood pressure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.

Choice B rationale:

Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

Choice C rationale:

Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.

Choice D rationale:

Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

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Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

A. Third intention. B. First intention. C. Second intention. D. Fourth intention.

Correct Answer is B

Explanation

Choice A rationale:

Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.

Choice B rationale:

First intention healing occurs when the wound edges are approximated, such as with sutures.

Choice C rationale:

Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.

Choice D rationale:

Fourth intention healing is not a recognized term in wound healing.

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A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

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Naxlex Comprehensive Predictor Exams

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

Correct Answer is C

Explanation

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

Correct Answer is B

Explanation

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