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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Free Nursing Study Resources

Correct Answer is C

Explanation

C. When collecting a stool specimen from a client with Clostridium difficile infection, the nurse should wear gloves to prevent the spread of the bacteria to themselves and other patients. Proper hand hygiene should also be performed after glove removal.
A. While alcohol-based hand rubs are effective against many types of bacteria and viruses, they are not effective against Clostridium difficile spores. Handwashing with soap and water is recommended for hand hygiene in cases of Clostridium difficile infection, as it is more effective at removing spores from the hands.
B. Chlorhexidine is a disinfectant commonly used for skin antisepsis, but it is not effective against
D. Placing the client in a protective environment is not typically necessary for clients with Clostridium difficile gastroenteritis unless they are immunocompromised or have other conditions that require protective isolation.

A. Receiving bronchodilator medication B. Weight loss of 2.8 kg (6.2 b) C. Hemoglobin 17 g/dl (12 to 16 g/dL) D. Wearing an oxygen device

Correct Answer is B

Explanation

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

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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

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Correct Answer is B

Explanation

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