A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

Hypertension

2+ edema

Crackles in lungs

Tachycardia

Answer and Explanation

The Correct Answer is D

D. Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
A. Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.

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Correct Answer is A

Explanation

A. Monitoring for occult blood in the stool is essential because long-term use of nonsteroidal anti- inflammatory drugs (NSAIDs) like ibuprofen can increase the risk of gastrointestinal bleeding and ulceration. Occult blood in the stool may indicate gastrointestinal bleeding, which can be a serious complication of chronic NSAID use.
B. While NSAIDs like ibuprofen can affect renal function and increase the risk of kidney damage, they are not directly associated with alterations in blood glucose levels.
C. Ibuprofen use is not typically associated with alterations in serum calcium levels
D. While monitoring urine for white blood cells may be relevant in the context of renal injury, it is not as specific or sensitive as other tests such as urinalysis or renal function tests.

A. Use moisturizing lotion while massaging the client's bony prominences. B. Instruct the client to sit on a rubber ring when seated in a chair. C. Place pillows between the client's knees when in a side-lying position. D. Raise the head of the client's bed to a 90° angle.

Correct Answer is C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

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A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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