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 A

Explanation

Choice A rationale:

Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.

Choice B rationale:

Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.

Choice C rationale:

Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.

Choice D rationale:

Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.

A. Irrigate the wound until the solution that is draining is clear. B. Chill the irrigant prior to the procedure. C. Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating. D. Flush the wound from the most contaminated area to the cleanest area.

Correct Answer is A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

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

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