A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

Bradycardia

Increased blood pressure

Warm, flushed skin

Decreased urine output

Answer and Explanation

The Correct Answer is B

A) Incorrect. Bradycardia is not typically an early sign of compensatory response to hypovolemia. The body often responds to hypovolemia with an increased heart rate (tachycardia).

B) Correct. In the early stages of hypovolemia, the body may attempt to compensate by increasing blood pressure to maintain perfusion to vital organs.

C) Incorrect. Warm, flushed skin may be present in the initial stages of hypovolemia, but it is not necessarily an early sign of compensatory response.

D) Incorrect. Decreased urine output is a later sign of hypovolemia when the body's compensatory mechanisms are no longer effective in maintaining blood flow to the kidneys.

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Correct Answer is C

Explanation

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.

A. Obtaining a written consent from the client. B. Assessing the client's level of pain. C. Administering prophylactic antibiotics. D. Taking the client's vital signs.

Correct Answer is A

Explanation

A) Correct. Before administering a blood transfusion, obtaining informed consent from the client is essential to ensure the client understands the procedure, its potential risks, and provides their voluntary agreement for the transfusion.

B) Incorrect. While pain assessment is important, it is not the most crucial action before starting a blood transfusion.

C) Incorrect. Prophylactic antibiotics are not typically administered before a blood transfusion unless specifically indicated for the client's condition.

D) Incorrect. While taking vital signs is important, obtaining consent is more critical before starting a blood transfusion.

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A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

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Naxlex Comprehensive Predictor Exams

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