A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
Bounding pulses
Restlessness
Warm skin
Brisk capillary refill
The Correct Answer is B
A. Active bleeding with significant blood is characterized by weak and thread pulses and not bounding pulses.
B. Restlessness can be a sign of hypovolemia and decreased tissue perfusion, which may occur with active bleeding.
C. Warm skin may not necessarily indicate active bleeding but rather normal thermoregulation or vasodilation.
D. Brisk capillary refill is a sign of adequate peripheral perfusion and is not typically associated with active bleeding which is characterized by delayed capillary refill.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While decreased appetite may be concerning, it is not typically considered a priority over potential complications related to immobility.
B. Left lower extremity tenderness could indicate deep vein thrombosis (DVT), a serious complication of prolonged bed rest that requires immediate attention to prevent pulmonary embolism.
C. Increased heart rate during physical activity may be expected after a period of bed rest and can be addressed with gradual reconditioning.
D. Musculoskeletal weakness is a common consequence of immobility and would be addressed as part of the client's rehabilitation but is not an immediate priority compared to potential complications like DVT.
Correct Answer is B
Explanation
A. Active bleeding with significant blood is characterized by weak and thread pulses and not bounding pulses.
B. Restlessness can be a sign of hypovolemia and decreased tissue perfusion, which may occur with active bleeding.
C. Warm skin may not necessarily indicate active bleeding but rather normal thermoregulation or vasodilation.
D. Brisk capillary refill is a sign of adequate peripheral perfusion and is not typically associated with active bleeding which is characterized by delayed capillary refill.
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