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 D

Explanation

A. This gait involves both crutches advancing simultaneously followed by both legs.

B. This gait involves swinging both legs and crutches forward at the same time.

C. This gait involves alternating movement of each crutch and leg, providing more stability but may be difficult for a client with limited weight-bearing on one leg.
D. In this gait, the client advances both crutches and the affected leg simultaneously, followed by the unaffected leg.

A. Press deeply into the client's upper abdomen left of midline to detect aortic pulsation. B. Use fingertips to lightly depress the right lower quadrant of the client's abdomen. C. Systematically percuss the client's abdomen. D. Observe the contours of the client's abdomen using a penlight E. Determine the presence of bowel sounds by using the diaphragm of the stethoscope.

Correct Answer is D,E,C,B,A

Explanation

A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.

E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.

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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

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

Correct Answer is D

Explanation

A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,E,C,B,A

Explanation

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