The nurse is assessing a patient in the immediate post-operative phase. Which of thr following assessment findings would be most indicative of post-operative hemorrhage?

Stow, shallow respirations and low heart rate

Fever and flushed skin

Disorientation and confusion in an elderly patient

Increasing heart rate and decreasing blood pressure

Answer and Explanation

The Correct Answer is D

A. Slow, shallow respirations and low heart rate:
Slow, shallow respirations and a low heart rate are not typical signs of postoperative hemorrhage. These signs might suggest respiratory or cardiac issues, but they are not specific to hemorrhage. In fact, hemorrhage is more likely to result in tachycardia (increased heart rate) and hypotension (low blood pressure) rather than bradycardia (low heart rate). Therefore, this finding is not indicative of post-operative hemorrhage.

B. Fever and flushed skin:
Fever and flushed skin are more commonly associated with infection rather than hemorrhage. After surgery, fever can be a sign of infection, particularly if it occurs 24-48 hours postoperatively. While infection can sometimes cause a rise in heart rate, it does not directly correlate with the symptoms of hemorrhage. Therefore, fever and flushed skin are not the most indicative of hemorrhage in the immediate postoperative phase.

C. Disorientation and confusion in an elderly patient:
Disorientation and confusion in the elderly post-operative patient can be concerning and may be caused by a variety of factors, such as medication side effects, electrolyte imbalances, or postoperative delirium. While confusion can occur with significant blood loss, it is not a primary indicator of hemorrhage. The signs of hemorrhage are more likely to include changes in vital signs, especially heart rate and blood pressure. Therefore, while disorientation and confusion should be monitored, they are not the most definitive sign of hemorrhage.

D. Increasing heart rate and decreasing blood pressure:
Increasing heart rate (tachycardia) and decreasing blood pressure (hypotension) are classic signs of hemorrhage. When blood loss occurs, the body compensates by increasing the heart rate to maintain cardiac output and attempting to constrict blood vessels. As hemorrhage progresses, blood volume decreases, which leads to a drop in blood pressure. This combination of tachycardia and hypotension is a key indicator of significant blood loss and requires immediate assessment and intervention. Therefore, this is the most indicative finding of postoperative hemorrhage.

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Correct Answer is A

Explanation

The client is showing signs of fluid overload due to heart failure exacerbation, including:

Progressive shortness of breath (fluid in the lungs)
Jugular venous distention (JVD) (increased central venous pressure)
Crackles in the lung bases (pulmonary congestion/edema)
Bounding pulse (increased circulating volume)

IV diuretics (e.g., Furosemide/Lasix) are the first-line treatment to rapidly reduce fluid overload by promoting diuresis and decreasing pulmonary congestion.

A. NG tube placement B. Low calorie and low protein diet C. Stool softeners and laxatives D. Barium contrast imaging studies

Correct Answer is A

Explanation

A. NG tube placement:
In patients with an exacerbation of inflammatory bowel disease (IBD), particularly in cases of severe flare-ups, the gastrointestinal tract may need rest, and the patient may have difficulty maintaining adequate nutrition. An NG (nasogastric) tube may be used for enteral feeding if the patient is unable to tolerate oral intake, or to provide bowel rest if indicated. Nutritional support via an NG tube can help provide essential nutrients and manage symptoms during an exacerbation, especially if the patient is experiencing severe nausea, vomiting, or malabsorption.

B. Low calorie and low protein diet:
During an IBD flare, the patient typically needs a higher-calorie, higher-protein diet to support healing and immune function. A low-calorie, low-protein diet would not be appropriate, as it would not provide the necessary nutrients for recovery and tissue repair. In fact, nutritional support is often one of the key components in managing IBD exacerbations. A diet rich in calories and protein is often recommended to prevent malnutrition.

C. Stool softeners and laxatives:
Stool softeners and laxatives are generally contraindicated during an IBD flare, as they can exacerbate diarrhea and increase bowel motility, which may worsen symptoms such as abdominal pain, cramping, and diarrhea. The focus during an exacerbation of IBD is typically on controlling inflammation, rest, and reducing bowel irritation, rather than promoting bowel movements.

D. Barium contrast imaging studies:
Barium contrast imaging studies are generally not performed during an acute exacerbation of IBD because they can cause further irritation to the inflamed bowel. Imaging studies are typically used for diagnosis and assessment of disease extent in a stable or chronic phase, rather than during an acute flare. The priority during a flare is managing symptoms and controlling inflammation, not conducting procedures that could aggravate the condition.

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