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,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 B
Explanation
A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow." This describes acute angle-closure glaucoma, not retinal detachment.
B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." Retinal detachment happens when the retina separates from its supporting tissues, including the blood vessels, leading to vision loss.
C. "Vision changes occur when the retina begins to break down and collect bits of debris." This describes age-related macular degeneration, not retinal detachment.
D. "Vision changes occur when the cloudy lens alters the passage of light through the eye." This describes cataracts, not retinal detachment.
Correct Answer is A
Explanation
A. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.
B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.
C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.
D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.
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