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","C","E"]
Explanation
A. Comparing the medication administration record with the medication container should occur before documentation to ensure accuracy.
B. This step ensures that the nurse is administering the correct medication to the client.
C. Comparing the medication against the administration record while removing it from the container helps prevent errors.
D. While important, this step does not directly involve comparing the medication container with the administration record.
E. Verifying the medication at the bedside ensures the right medication is given to the right patient at the right time.
Correct Answer is D
Explanation
A. This represents a situational loss, as it is related to external circumstances such as economic changes.
B. This also represents a situational loss, as it involves the loss of material possessions.
C. This is a situational loss, specifically a loss of a loved one, which is different from a maturational loss.It is unexpected andoccurs due to an external event or situation.
D. This is an example of a maturational loss, as it involves a normal life transition that brings about feelings of loss and adjustment.
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