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 B
Explanation
A. A transfer belt should be removed after the transfer is completed, as it can cause skin irritation or pressure ulcers if left in place for too long.
B. Lowering the footplates before transferring the client from the bed helps to prevent injury to the client's feet and legs during the transfer.
C. Backing the wheelchair into the elevator is not necessary, as long as there is enough space to maneuver the wheelchair inside.
D. Positioning the client so their weight is shifted forward can make the transfer more difficult and increase the risk of falling.
Correct Answer is D
Explanation
A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.
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