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 A

Explanation

A. Desmopressin acetate: This synthetic form of antidiuretic hormone (ADH) reduces excessive urine output by increasing water reabsorption in the kidneys. It helps restore fluid balance and prevent dehydration in diabetes insipidus. Without treatment, continued polyuria can lead to severe dehydration and electrolyte imbalances.

B. Spironolactone: This potassium-sparing diuretic promotes sodium and water excretion by blocking aldosterone receptors. It is used to treat conditions like heart failure and hyperaldosteronism but would worsen polyuria and dehydration in diabetes insipidus.

C. Furosemide: This loop diuretic inhibits sodium and chloride reabsorption in the kidneys, leading to increased urine output. Administering it to a client with diabetes insipidus would further aggravate excessive fluid loss and the risk of dehydration.

D. Dopamine: This vasopressor is used to improve cardiac output and blood pressure in conditions like shock. It does not affect ADH levels or urine concentration and would not help manage the excessive diuresis seen in diabetes insipidus.

A. Thalassemia B. Rheumatoid arthritis C. Thrombocytopenia D. COPD

Correct Answer is C

Explanation

A. Thalassemia: A genetic blood disorder affecting hemoglobin production. While patients with severe anemia may have an increased bleeding risk, thalassemia itself is not a contraindication to heparin. Caution is needed if the patient has splenomegaly or significant anemia.

B. Rheumatoid arthritis: An autoimmune condition that can increase bleeding risk due to chronic inflammation and medication use, such as NSAIDs or corticosteroids. However, heparin is not contraindicated unless there is an associated bleeding disorder or severe thrombocytopenia.

C. Thrombocytopenia: A condition characterized by a low platelet count, significantly increasing the risk of bleeding. Heparin use can worsen this condition, especially in cases of heparin-induced thrombocytopenia (HIT), which can lead to both bleeding and thrombosis.

D. COPD: A chronic lung disease that does not directly contraindicate heparin therapy. While COPD patients may be at risk for deep vein thrombosis due to immobility, heparin remains a standard prophylactic treatment unless there are other bleeding risks.

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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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