A nurse is monitoring a client for potential hemorrhage after a medical procedure. Which vital sign change is an early indicator of internal bleeding?
Hypertension
Bradycardia
Tachypnea
Hyperthermia
The Correct Answer is C
A. Hypertension is not an early sign of hemorrhage; instead, hypotension occurs as blood loss progresses.
B. Bradycardia is not an expected response; tachycardia is more common due to compensatory mechanisms.
C. Tachypnea is an early indicator of internal bleeding as the body attempts to compensate for decreased oxygen delivery by increasing respiratory rate.
D. Hyperthermia is not associated with hemorrhage; instead, hypothermia can occur with significant blood loss.
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Related Questions
Correct Answer is D
Explanation
A) Incorrect. While the respiratory rate is an important vital sign to monitor, it does not directly indicate the effectiveness of a blood transfusion.
B) Incorrect. Blood pressure is a critical vital sign, but it is not specific to assessing the effectiveness of a blood transfusion.
C) Incorrect. Urinary output is essential for assessing kidney function and fluid balance, but it does not directly reflect the impact of a blood transfusion.
D) Correct. Monitoring the hemoglobin level is crucial to determine if the blood transfusion has been effective in increasing the client's red blood cell count and improving oxygen-carrying capacity.
Correct Answer is C
Explanation
A) Incorrect. A complete blood count (CBC) provides information about the client's red blood cells, white blood cells, and platelets, but it does not directly assess clotting function.
B) Incorrect. Serum electrolytes help assess the body's fluid balance and various organ functions, but they do not specifically indicate clotting function.
C) Correct. Prothrombin time (PT) is a measure of the time it takes for the blood to clot, primarily assessing the function of the extrinsic pathway of coagulation. It is an essential test in evaluating clotting disorders.
D) Incorrect. Blood glucose level is not directly related to clotting function and is more indicative of a client's metabolic status.
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