A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?
Temperature of 38° C (100.4° F)
Respiratory rate of 10/min
Heart rate of 112/min
Blood pressure of 136/88 mm Hg
The Correct Answer is C
A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Direct all communication through the client's family." While family members may assist in communication, they may omit, alter, or misunderstand medical information. Using a trained medical interpreter ensures accurate and confidential communication.
B. "Limit instructions to simple and short one-sentence instructions." While clear, simple instructions are helpful, language barriers still exist. This does not fully address the client’s difficulty in understanding.
C. "Ask a coworker who speaks the client's language to translate information." A coworker may not be a certified medical interpreter and could misinterpret critical information. Medical translation should always be done by a qualified interpreter.
D. "Find an available interpreter to help with communication." A trained medical interpreter provides accurate, unbiased, and professional translation, ensuring that the client fully understands their care and can make informed decisions.
Correct Answer is C
Explanation
A. Flush the client's tube with 5 mL of water. – This is incorrect because the standard amount of water used to flush a feeding tube is typically 30–50 mL to maintain patency and prevent clogging.
B. Place the client in a supine position. – This is incorrect because the client should be placed in a semi-Fowler’s or Fowler’s position (at least 30–45 degrees) to reduce the risk of aspiration.
C. Check the pH level of the client's gastric contents. – This is the correct answer. Checking the pH of gastric contents (typically ≤5.5) helps confirm proper tube placement before administering feedings, reducing the risk of aspiration.
D. Check the patency of the client's tube every 8 hr. – This is incorrect because tube patency should be checked before each feeding or medication administration, not just every 8 hours.
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