A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

Hypertension

2+ edema

Tachycardia

Crackles in lungs

Answer and Explanation

The Correct Answer is C

A. Hypertension: Elevated blood pressure is not a typical sign of bleeding. In cases of significant blood loss, compensatory mechanisms usually lead to hypotension rather than hypertension due to reduced circulating volume. A hypertensive response may occur due to pain or stress but does not indicate hemorrhage.

B. 2+ edema: Postoperative edema can occur from fluid shifts, inflammation, or IV fluid administration but is not a direct indicator of active bleeding. Bleeding is more likely to cause signs of hypovolemia, such as tachycardia or hypotension, rather than localized swelling.

C. Tachycardia: A common early sign of bleeding, as the body compensates for decreased blood volume by increasing heart rate to maintain oxygen delivery. Persistent tachycardia in a postoperative client should raise suspicion for internal bleeding, especially if accompanied by hypotension or pallor.

D. Crackles in lungs: Crackles are usually linked to fluid overload, pneumonia, or heart failure rather than bleeding. Pulmonary congestion may develop after aggressive IV fluid resuscitation, but bleeding primarily manifests with hemodynamic instability rather than respiratory symptoms.

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Correct Answer is D

Explanation

A. Place pillows under the client's knees: Placing pillows under the knees can lead to venous stasis, increasing the risk of deep vein thrombosis (DVT). Prolonged knee flexion can also reduce circulation and contribute to joint stiffness. Instead, the client should be encouraged to keep their legs extended and change positions frequently to promote blood flow.

B. Avoid use of anticoagulants: Anticoagulants are commonly prescribed after surgery to prevent thromboembolic complications such as DVT and pulmonary embolism. Avoiding them may increase the client's risk of clot formation, especially if they have limited mobility. The decision to withhold anticoagulation should be based on specific contraindications rather than routine avoidance.

C. Discourage leg exercises while in bed: Leg exercises help prevent blood pooling in the lower extremities, reducing the risk of DVT. Discouraging movement can lead to complications such as impaired circulation, muscle stiffness, and clot formation. Encouraging active and passive range-of-motion exercises supports recovery and decreases the likelihood of postoperative complications.

D. Apply compression stockings to the lower extremities: Compression stockings help improve venous return and reduce the risk of clot formation by preventing blood from pooling in the lower extremities. They are particularly beneficial for clients with limited mobility after surgery. Using them in combination with early ambulation and anticoagulation therapy further decreases the risk of thromboembolic events.

A. Place a tongue blade at the bedside. B. Dim the overhead lights. C. Assist the client to ambulate every 4 hr. D. Apply a warming blanket. E. Have suction equipment at the bedside.

Correct Answer is ["B","E"]

Explanation

A. Place a tongue blade at the bedside: Keeping a tongue blade at the bedside is not recommended because attempting to insert an object into the mouth during a seizure can cause injury to the teeth, gums, or airway. Instead, the focus should be on maintaining a safe environment and protecting the client from harm.

B. Dim the overhead lights: Meningitis can cause photophobia, or sensitivity to light, which can worsen discomfort and potentially trigger seizures. Dimming the lights helps reduce sensory stimulation and promotes comfort, decreasing the risk of further neurological agitation.

C. Assist the client to ambulate every 4 hr: Clients experiencing seizures should have activity restrictions to prevent falls and injuries. Ambulation should be supervised and only encouraged once the client is stable. Frequent rest is preferred to minimize exhaustion, which can contribute to seizure activity.

D. Apply a warming blanket: Meningitis can cause fever, but applying a warming blanket is not appropriate unless the client is experiencing hypothermia. Fever management typically involves antipyretics and cooling measures, such as tepid sponge baths or light clothing, rather than warming interventions.

E. Have suction equipment at the bedside: During a seizure, excessive secretions or impaired airway protection can lead to aspiration. Having suction equipment readily available allows for quick clearance of the airway once the seizure subsides, reducing the risk of respiratory complications.

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A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

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