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

Answer and Explanation

Correct Answer : A,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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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.

A. Check the client's vital signs. B. Cover the wound with a moist, sterile gauze dressing. C. Assess the client's pain level. D. Obtain a culture and sensitivity of the wound drainage

Correct Answer is B

Explanation

A. Check the client's vital signs. While vital signs are important for overall assessment, the immediate priority when faced with wound dehiscence is to protect the wound and prevent further contamination or damage.

B. Cover the wound with a moist, sterile gauze dressing. The first priority is to cover the wound with a moist, sterile dressing to protect it from infection and to manage the drainage. This helps in creating a barrier to prevent contamination and supports the wound environment for healing.

C. Assess the client's pain level. Pain assessment is important but not the immediate priority in this case. Managing the wound and preventing further complications is more critical.

D. Obtain a culture and sensitivity of the wound drainage. While obtaining a culture is important to identify any infection, it is not the first action. Protecting the wound from further contamination comes first.

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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)

Nursing Test Bank

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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)