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","B","D","E"]

Explanation

Chest pain radiating to the left arm is characteristic for angina in coronary artery disease. This is suggested more by the client’s medical history of hypertension, hyperlipidemia and type 2 diabetes mellitus.

Clients with angina are scheduled for diagnostic cardiac catheterization to assess the extent of coronary blockage

Heparin is used to prevent the propagation of a clot that is formed on an unstable atherosclerotic plaque. Beta blockers are prescribed to lower the heart rate. This reduces the myocardial demand for oxygen.

The firstline medication include antiplatelets unless there's concurrent venous thromboembolism.

Keeping the client NPO within 2 hours of the procedure is important to prevent aspiration whole under sedation.

Ambulation increases demand on the heart which may worsen the pain Antibiotics have no role in coronary artery disease.

A. Turn the client on their side. B. Perform a neurologic check. C. Obtain the client's vital signs. D. Notify the rapid response team.

Correct Answer is A

Explanation

A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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