A client with multiple injuries to the head, chest, and abdomen has had their airway stabilized and is breathing on their own. Which symptom would lead the nurse to suspect internal hemorrhaging even when the nurse does not see any bleeding?

Increased sweating

Increased redness at the site

Increased abdominal distention

Increased blood pressure

Answer and Explanation

The Correct Answer is C

A. Increased sweating: This is incorrect. Increased sweating is not typically indicative of internal hemorrhaging. It can be associated with various conditions but is not a specific sign of internal bleeding.
B. Increased redness at the site: This is incorrect. Increased redness would more likely be associated with localized infection or inflammation rather than internal hemorrhaging.
C. Increased abdominal distention: This is correct. Increased abdominal distention can be a sign of internal hemorrhaging, particularly if blood accumulates in the abdominal cavity (hemoperitoneum), leading to abdominal swelling and discomfort.
D. Increased blood pressure: This is incorrect. Internal hemorrhaging often leads to hypotension rather than increased blood pressure, as blood volume decreases and the body attempts to compensate.

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Correct Answer is B

Explanation

A. Manually irrigate the catheter: This action is premature if the issue is due to a kink or obstruction in the tubing. Manual irrigation should only be performed if other less invasive measures do not resolve the issue.
B. Check the catheter tubing for kinks: This is the first step to take as kinks in the tubing can obstruct the flow of urine. Identifying and correcting kinks may resolve the problem without further intervention.
C. Notify the healthcare provider: This step may be necessary if other interventions do not resolve the issue, but it is not the first action.
D. Adjust the rate of the bladder irrigant: This may be relevant if the problem is related to the irrigation rate, but checking for kinks should be done first to ensure proper catheter function.

A. "It provides an area where clients can be provided a shower and privacy." B. "It provides a centralized area for the triage of all clients as they arrive to the facility." C. "It prevents secondary contamination to the facility and its healthcare providers." D. "It serves as a holding area that isolates the clients who have been exposed to the agent."

Correct Answer is C

Explanation

A. "It provides an area where clients can be provided a shower and privacy." This is incorrect. While decontamination areas may include showers for client decontamination, the primary rationale is more focused on preventing contamination rather than providing privacy.
B. "It provides a centralized area for the triage of all clients as they arrive to the facility." This is incorrect. Centralized triage is important but not the primary reason for a decontamination area.
C. "It prevents secondary contamination to the facility and its healthcare providers." This is correct. The primary rationale for a designated decontamination area is to prevent secondary contamination of the facility and its personnel by removing contaminants from individuals before they enter the healthcare environment.
D. "It serves as a holding area that isolates the clients who have been exposed to the agent." This is incorrect. Isolation may be a component, but the main purpose of decontamination is to prevent contamination spread.

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A client with multiple injuries to the head, chest, and abdomen has had their airway stabilized and is breathing on their own. Which symptom would lead the nurse to suspect internal hemorrhaging even when the nurse does not see any bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

The nurse is teaching a class on bioterrorism. Which statement by a student indicates understanding of the primary rationale for designating an area for decontamination?

Correct Answer is C

Explanation

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