A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Hypertension

Diarrhea

Fatigue

Bradycardia

Answer and Explanation

The Correct Answer is C

A. Hypertension: Anemia is more likely to be associated with hypotension rather than hypertension. The body often responds to anemia by increasing heart rate and cardiac output to compensate for reduced oxygen-carrying capacity.

B. Diarrhea: Anemia itself is not directly associated with diarrhea. Excess blood loss can lead to anemia, but diarrhea is not a typical manifestation of anemia.

C. Fatigue: This is the correct answer. Fatigue is a common symptom of anemia, as reduced oxygen delivery to tissues can lead to feelings of weakness, tiredness, and lack of energy.

D. Bradycardia: Anemia is more likely to be associated with compensatory tachycardia (increased heart rate) rather than bradycardia. The body attempts to maintain oxygen delivery to tissues by increasing cardiac output.

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Correct Answer is D

Explanation

A. Serum amylase: Serum amylase is an enzyme associated with pancreatic function, and its elevation is not specific to myocardial infarction.

B. Unconjugated bilirubin: Elevation of unconjugated bilirubin is associated with liver function and hemolysis, not specifically with myocardial infarction.

C. Aspartate aminotransferase (AST): While AST may be elevated in conditions affecting the heart, it is not as specific or sensitive for myocardial infarction as troponin I.

D. Troponin I: This is the correct answer. Troponin I is a cardiac-specific biomarker released into the bloodstream when there is damage to cardiac muscle, such as during a myocardial infarction. Troponin I levels start to rise within 3-4 hours after the onset of myocardial infarction, making it a crucial marker for early detection.

A. Call emergency services for the client. B. Increase the oxygen flow to 3 L/min. C. Have the client cough and expectorate secretions. D. Assess the client's respiratory status.

Correct Answer is D

Explanation

A. Call emergency services for the client: While difficulty breathing is a concerning symptom, the immediate priority is to assess the client's respiratory status to determine the cause and appropriate interventions. Calling emergency services may be necessary based on the assessment findings, but assessment comes first.

B. Increase the oxygen flow to 3 L/min: Adjusting oxygen flow may be part of the intervention, but it should be based on a comprehensive assessment of the client's respiratory status. Simply increasing the oxygen flow without a thorough assessment may not address the underlying issue.

C. Have the client cough and expectorate secretions: This action may be appropriate if the client is experiencing difficulty breathing due to increased bronchial secretions. However, assessment is needed to determine the cause of the difficulty breathing before implementing interventions.

D. Assess the client's respiratory status: This is the correct answer. Assessment is the priority when a client with COPD on oxygen reports difficulty breathing. The nurse should gather information about the client's respiratory rate, effort, oxygen saturation, lung sounds, and overall respiratory distress to determine the appropriate course of action.

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A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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