A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

restlessness, rising pulse, and falling blood pressure.

lethargy, falling pulse, and rising blood pressure.

headache, rising pulse, and falling blood pressure.

restlessness, falling pulse, and rising blood pressure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.

Choice B rationale:

Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

Choice C rationale:

Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.

Choice D rationale:

Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

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Correct Answer is B

Explanation

Choice A rationale:

An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.

Choice B rationale:

A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.

Choice D rationale:

A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.

A. Hydrogel dressing. B. Polymeric membrane dressing. C. Hydrofiber dressing. D. Hydrocolloid dressing.

Correct Answer is C

Explanation

Choice A rationale:

Hydrogel dressings are used for wounds with little to no exudate. They are not suitable for wounds with significant exudate.

Choice B rationale:

Polymeric membrane dressings are used for dry wounds with or without depth. They are not suitable for wounds with significant exudate.

Choice C rationale:

Hydrofiber dressings are used for wounds with moderate to high amounts of exudate. They are suitable for wounds with significant exudate.

Choice D rationale:

Hydrocolloid dressings are used for wounds that have minimal to moderate exudate. They are not suitable for wounds with significant exudate.

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A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

Correct Answer is C

Explanation

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