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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Place the head of the bed flat before using the incentive spirometer." The client should be in a semi-Fowler’s or high-Fowler’s position (sitting upright) to maximize lung expansion.
B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." Holding the breath allows for maximum lung expansion and helps prevent atelectasis (lung collapse).
C. "Use the incentive spirometer every 3 hours while awake." The incentive spirometer should be used every 1 to 2 hours while awake to promote lung expansion and prevent complications such as pneumonia.
D. "Breathe in through your nose when using the incentive spirometer." The client should inhale deeply through the mouth, not the nose, to ensure proper lung inflation.

A. Place the bell of the stethoscope on the client's chest. B. Follow a systematic pattern from side-to-side moving down the client's chest. C. Ask the client to breathe in deeply through his nose. D. Instruct the client to sit erect with their head tilted slightly backward.

Correct Answer is B

Explanation

A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.

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A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?

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