A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
[Select All that Apply)

Hypotension

Diaphoresis

Тасhурпеа

Bradycardia

Diarrhea

Answer and Explanation

Correct Answer : A,C

A. Hypotension: Hypotension is a common sign of hemorrhage. It occurs due to significant blood loss leading to decreased circulating blood volume and reduced cardiac output, which in turn lowers blood pressure. In the context of postoperative care, hypotension is a critical sign that may indicate internal bleeding.

B. Diaphoresis: Diaphoresis (excessive sweating) can be an autonomic response to acute blood loss and shock. The body tries to compensate for reduced blood volume and pressure by activating the sympathetic nervous system, which results in sweating as part of the body's effort to maintain perfusion to vital organs.

C. Tachypnea: Tachypnea (rapid breathing) is a compensatory mechanism in response to decreased oxygen delivery due to blood loss. The body increases respiratory rate to improve oxygen uptake and delivery to tissues, which is vital when there is reduced blood volume from hemorrhage.

D. Bradycardia: Bradycardia (slow heart rate) is not typically associated with hemorrhage. Instead, hemorrhage usually causes tachycardia (rapid heart rate) as the body attempts to maintain cardiac output and compensate for the loss of blood volume. Bradycardia could indicate other issues such as increased intracranial pressure or a vagal response but is not a common sign of acute hemorrhage.

E. Diarrhea: Diarrhea is not a sign of hemorrhage. It is more commonly associated with gastrointestinal issues such as infections, inflammatory bowel diseases, or reactions to medications. Hemorrhage typically affects cardiovascular parameters rather than causing gastrointestinal symptoms like diarrhea.

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Correct Answer is C

Explanation

A. 2 hr after obtaining blood from the blood bank. Blood should be started as soon as possible, ideally within 30 minutes to minimize the risk of bacterial growth. Waiting for 2 hours is not appropriate.

B. When the client states he is ready to start the infusion. The client’s readiness should be considered, but the timing should be based on clinical guidelines and safety protocols, not just the client’s preference.

C. As soon as the nurse can prepare the client and the administration set. Blood products should be infused as soon as possible after preparation to reduce the risk of bacterial contamination and ensure efficacy.

D. When the client has finished eating lunch. The infusion timing should not be delayed for non-essential reasons like meal completion unless the client is experiencing issues that could interfere with the transfusion.

A. Stop the infusion of blood, B. Inform the provider. C. Obtain a urine specimen. D. Notify the laboratory.

Correct Answer is A

Explanation

A. Stop the infusion of blood. The client’s symptoms suggest a possible acute hemolytic transfusion reaction, which is a life-threatening emergency. The first and most critical action is to stop the blood transfusion immediately to prevent further reaction and additional hemolysis.

B. Inform the provider: This is an important action but should be done after stopping the transfusion to prevent further complications.

C. Obtain a urine specimen: This is done to check for hemoglobinuria, but it is not the immediate priority.

D. Notify the laboratory: This is part of the follow-up procedure but should be done after stopping the transfusion and stabilizing the patient.

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A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage? [Select All that Apply)

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Naxlex Comprehensive Predictor Exams

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
[Select All that Apply)