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 ["B","E"]

Explanation

A. Massage over erythematous bony prominences: Incorrect. Massaging over areas of erythema (redness) can cause further damage to the underlying tissues and should be avoided. It may exacerbate tissue injury and increase the risk of skin breakdown.

B. Use pillows to keep heels off the bed surface: Correct. Elevating the heels with pillows helps to reduce pressure and prevent pressure ulcers by keeping them off hard surfaces. This is a recommended practice to reduce the risk of heel pressure ulcers.

C. Implement turning schedule every 4 hr: Incorrect. A turning schedule of every 2 hours is generally recommended to prevent pressure ulcers. Four hours is too long and increases the risk of skin breakdown in immobile patients.

D. Keep the client's skin dry with powder: Incorrect. Powders can dry out the skin and increase friction, potentially leading to skin breakdown. It's more important to maintain moisture balance and avoid the use of powders on skin at risk.

E. Minimize skin exposure to moisture: Correct. Moisture can contribute to skin breakdown, especially in incontinent patients. It is crucial to keep the skin clean and dry to prevent moisture-associated skin damage.

A. 4 hr B. 2 hr C. 8 hr D. 6 hr

Correct Answer is A

Explanation

A. 4 hr - The total infusion time for packed RBCs should not exceed 4 hours. Infusing beyond this period increases the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications.

B. 2 hr - While blood can be infused in 2 hours for some patients, especially in non-emergent situations, the standard maximum time allowed is 4 hours to prevent complications.

C. 8 hr - Infusing blood over 8 hours is too long and increases the risk of bacterial contamination and decreased efficacy of the blood product.

D. 6 hr - Similar to 8 hours, a 6-hour infusion time is too lengthy and poses significant risks for bacterial growth and sepsis.

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A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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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)

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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)