A nurse is caring for a client with suspected internal bleeding. Which assessment finding requires immediate intervention?
Client reports feeling dizzy and lightheaded.
Client's blood pressure is slightly decreased.
Client's skin is pale and cool to the touch.
Client's heart rate is within the normal range.
The Correct Answer is A
A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.
B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.
C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.
D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Topical antiseptics, such as hydrogen peroxide or alcohol, can help prevent infection but are safe to use on minor cuts when applied correctly.
B) Correct. Applying direct pressure to the bleeding site for at least 10 minutes helps control minor bleeding and allows the blood to clot, reducing the risk of excessive bleeding.
C) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding. It should not be used to stop bleeding quickly without medical guidance.
D) Incorrect. Elevating the affected limb above the heart level is not typically necessary for minor bleeding episodes and may not be practical for all bleeding sites.
Correct Answer is D
Explanation
A) Incorrect. Hemoglobin levels may initially be normal or slightly decreased, but they would decrease later due to the body's compensatory response to dilute the remaining blood.
B) Incorrect. Platelet count may not be significantly affected in the early stages of hemorrhage. It is mainly responsible for clot formation, which becomes more relevant in the later stages.
C) Incorrect. In the early stages of hemorrhage, the white blood cell count is not significantly affected. It plays a role in fighting infection and inflammation.
D) Correct. Hematocrit levels represent the proportion of red blood cells in the blood. During early stages of hemorrhage, there is a loss of red blood cells, leading to decreased hematocrit levels.
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