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

Crackles in lungs

Tachycardia

Answer and Explanation

The Correct Answer is D

D. Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
A. Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.

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Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

A. Provide humidified oxygen. B. Administer antibiotic medication. C. Implement fluid restriction D. Administer acetaminophen orally.

Correct Answer is A

Explanation

A. Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.

B. Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.

D. While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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