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

Answer and Explanation

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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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.

A. "Avoid the use of topical antiseptics on minor cuts." B. "Apply direct pressure to the bleeding site for at least 10 minutes." C. "Take over-the-counter aspirin to help stop bleeding quickly." D. "Elevate the affected limb above the heart level."

Correct Answer is B

Explanation

A) Incorrect. Topical antiseptics, such as hydrogen peroxide or alcohol, can help prevent infection but are safe to use on minor cuts when applied correctly.

B) Correct. Applying direct pressure to the bleeding site for at least 10 minutes helps control minor bleeding and allows the blood to clot, reducing the risk of excessive bleeding.

C) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding. It should not be used to stop bleeding quickly without medical guidance.

D) Incorrect. Elevating the affected limb above the heart level is not typically necessary for minor bleeding episodes and may not be practical for all bleeding sites.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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