A nurse is monitoring a client for potential hemorrhage after a medical procedure. Which vital sign change is an early indicator of internal bleeding?

A) Incorrect. Administering oxygen is essential for a client experiencing difficulty breathing, but the nurse's immediate action should be to stop the blood transfusion and notify the healthcare provider.

B) Incorrect. While assessing the client's vital signs is important, the priority action is to stop the blood transfusion and seek immediate medical assistance.

C) Correct. Sudden difficulty breathing and chest pain after a blood transfusion may indicate an allergic reaction or transfusion-related acute lung injury (TRALI). The nurse should stop the transfusion immediately and inform the healthcare provider.

D) Incorrect. Elevating the head of the client's bed may be helpful in managing respiratory distress, but it is not the priority when there is a potential adverse reaction to the blood transfusion.

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.