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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
E.
Choice A rationale:
Increased immunity is not a characteristic of aging. In fact, immunity decreases with age, which can slow healing.
Choice B rationale:
Atherosclerosis, or hardening of the arteries, can reduce blood flow to tissues and slow healing.
Choice C rationale:
Metabolism slows with age, which can delay the body’s ability to repair and regenerate tissues.
Choice D rationale:
Excessive production of blood factors is not a characteristic of aging. Blood factors are typically produced in response to injury or illness.
Choice E rationale:
Diminished lung function can reduce oxygen supply to tissues, slowing healing.
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.
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