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:

While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.

Choice B rationale:

Placing a discard bag close to the wound can increase the risk of infection.

Choice C rationale:

Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.

Choice D rationale:

Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.

A. Supine with the head tilted toward the right eye. B. Upright with the head tilted toward the left eye. C. Upright with the head hyperextended. D. Supine with the head hyperextended.

Correct Answer is A

Explanation

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

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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

When preparing to change a sterile dressing over an incision, it is most important to remember to:

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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