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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response is appropriate because it shows empathy, respect, and interest in the client's feelings and thoughts. It also invites the client to explore and clarify their meaning of purpose and how it relates to their retirement.
B. This response is dismissive of the client’s concern.
C. While hobbies can be fulfilling, this response does not address the client's feelings of purposelessness directly.
D. This response minimizes the client's feelings and does not offer constructive solutions to address their concerns.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
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