A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?
Temperature of 38° C (100.4° F)
Respiratory rate of 10/min
Heart rate of 112/min
Blood pressure of 136/88 mm Hg
The Correct Answer is C
A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use IV tube ports when injecting medications." Latex-free IV ports should be used instead of rubber stoppers found in some IV bags and vials.
B. "Remove medication from multi-dose vials with the stopper in place." Many vial stoppers contain latex, so the nurse should use single-dose vials or vials labeled as latex-free.
C. "Secure loose cords in stockinette with tape." Stockinettes are sometimes made with latex, posing a risk to the client. Non-latex materials should be used instead.
D. "Schedule the client's surgery as the last procedure of the day." Clients with latex allergies should be scheduled first to minimize exposure to airborne latex particles from gloves and equipment used earlier in the day.
Correct Answer is ["440"]
Explanation
Total Intake:
0.9% sodium chloride IV infusion = 600 mL
Cefazolin in D5W IV bolus = 100 mL
Total intake = 600 + 100 = 700 mL
Total Output:
Emesis = 200 mL
Voided urine = 40 mL
Straight catheter urine = 20 mL
Total output = 200 + 40 + 20 = 260 mL
Difference (Intake - Output):
700 mL - 260 mL = 440 mL
Final Answer:
440 mL
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