A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
[Select All that Apply)
Hypotension
Diaphoresis
Тасhурпеа
Bradycardia
Diarrhea
Correct Answer : A,B,C
A. Hypotension: Hypotension is a common sign of hemorrhage. It occurs due to significant blood loss leading to decreased circulating blood volume and reduced cardiac output, which in turn lowers blood pressure. In the context of postoperative care, hypotension is a critical sign that may indicate internal bleeding.
B. Diaphoresis: Diaphoresis (excessive sweating) can be an autonomic response to acute blood loss and shock. The body tries to compensate for reduced blood volume and pressure by activating the sympathetic nervous system, which results in sweating as part of the body's effort to maintain perfusion to vital organs.
C. Tachypnea: Tachypnea (rapid breathing) is a compensatory mechanism in response to decreased oxygen delivery due to blood loss. The body increases respiratory rate to improve oxygen uptake and delivery to tissues, which is vital when there is reduced blood volume from hemorrhage.
D. Bradycardia: Bradycardia (slow heart rate) is not typically associated with hemorrhage. Instead, hemorrhage usually causes tachycardia (rapid heart rate) as the body attempts to maintain cardiac output and compensate for the loss of blood volume. Bradycardia could indicate other issues such as increased intracranial pressure or a vagal response but is not a common sign of acute hemorrhage.
E. Diarrhea: Diarrhea is not a sign of hemorrhage. It is more commonly associated with gastrointestinal issues such as infections, inflammatory bowel diseases, or reactions to medications. Hemorrhage typically affects cardiovascular parameters rather than causing gastrointestinal symptoms like diarrhea.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a venous duplex ultrasound. These symptoms suggest a deep vein thrombosis (DVT), and a venous duplex ultrasound is the standard diagnostic test to confirm the presence of a thrombus in the veins.
B. Obtain impedance plethysmography: This is less commonly used than ultrasound and may not provide as clear a diagnosis.
C. Monitor Homan's sign: Homan's sign is no longer considered reliable or safe for diagnosing DVT due to the risk of dislodging a thrombus.
D. Apply cold therapy to the affected leg: Cold therapy is not appropriate for DVT as it does not treat the underlying issue and could potentially cause vasoconstriction, worsening the condition.
Correct Answer is D
Explanation
A. Sleep on the abdomen to facilitate wound healing: Clients are usually advised to avoid sleeping on the side of the operated eye or on the abdomen to prevent pressure on the eye.
B. Bend at the waist to pick objects up from the floor: Bending at the waist can increase intraocular pressure, which is not advisable post-surgery.
C. Notify the surgeon if white drainage develops on the eyelids: White drainage may be a sign of normal healing or minor irritation; however, yellow or green discharge would be more concerning for infection.
D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Lifting heavy objects can increase intraocular pressure and potentially disrupt the healing process after cataract surgery. The client should avoid such activities to promote proper healing.
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