A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?

Bounding pulses

Restlessness

Warm skin

Brisk capillary refill

Answer and Explanation

The Correct Answer is B

A.   Active bleeding with significant blood is characterized by weak and thread pulses and not bounding pulses.
B.   Restlessness can be a sign of hypovolemia and decreased tissue perfusion, which may occur with active bleeding.
C.   Warm skin may not necessarily indicate active bleeding but rather normal thermoregulation or vasodilation.
D.   Brisk capillary refill is a sign of adequate peripheral perfusion and is not typically associated with active bleeding which is characterized by delayed capillary refill.

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Correct Answer is A

Explanation

A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

A. Hold the dropper 3 cm (1.2 in) away from the client's eye. B. Massage the client's eyelids for 20 seconds after instillation. C. Wait 5 min between the administration of each medication. D. Ask the client to close their eyes tightly after instilling each medication.

Correct Answer is C

Explanation

A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.

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A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?

Nursing Test Bank

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A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?