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
Correct Answer : A,B,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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Wash with plain soap and water." While cleanliness is important, plain soap can be drying and irritating. Gentle cleansing is better, using products that do not strip the skin of natural oils.
B. "Sit in the sun for 10 minutes per day." Sun exposure can exacerbate radiation dermatitis and should be avoided. The skin needs protection from additional UV damage.
C. "Apply moist heat." Moist heat can further irritate already sensitive skin and is not recommended for treating radiation-induced skin reactions.
D. "Apply hydrating lotions." Hydrating lotions help to soothe and moisturize the skin, promoting healing and alleviating dryness and scaling caused by radiation treatment. Use products specifically recommended for sensitive or radiated skin.
Correct Answer is A
Explanation
A. “I need something for the pain in my eye. I can't stand it." Severe pain after cataract surgery is unusual and could indicate complications such as increased intraocular pressure or infection. This should be reported immediately to the provider for further evaluation.
B. "It’s hard to see with a patch on one eye. I'm afraid of falling": This is a common concern and relates to mobility safety, not a sign of a surgical complication.
C. "My eye really itches, but I'm trying not to rub it.": Itching can be a normal response post-surgery due to healing. Patients should avoid rubbing the eye, and this does not necessarily indicate a complication.
D. "The bright light in this room is really bothering me.": Photophobia or sensitivity to light can be common postoperatively and is usually not a sign of a serious issue.
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