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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.
B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.
C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.
D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.
Correct Answer is A
Explanation
A. Exposure to radiation - Exposure to high levels of radiation is a known risk factor for developing CML. Historical data, such as from atomic bomb survivors, show a higher incidence of leukemia, including CML, among those exposed to radiation.
B. Family history - CML is generally not associated with a significant familial risk. It is more commonly linked to acquired genetic mutations rather than inherited predispositions.
C. Another type of cancer - Having another type of cancer does not directly increase the risk of developing CML. However, treatments for other cancers, like radiation therapy, might increase risk.
D. Genetic mutation - The development of CML is associated with a specific acquired genetic mutation known as the Philadelphia chromosome (translocation between chromosomes 9 and 22), rather than inherited genetic mutations.
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