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 B
Explanation
A. "Although this is your first incident, we will have to terminate your employment." This response is punitive and does not align with a just culture, which seeks to identify the cause of errors rather than immediately disciplining staff.
B. "We will review the incident report to determine the cause of the missed medication." This aligns with just culture principles by focusing on finding the root cause (e.g., workload issues, system inefficiencies) rather than blaming the nurse.
C. "I will need to report this incident to the state board of nursing." A missed medication dose that caused no harm typically does not require reporting to the state board. Just culture focuses on improving processes rather than unnecessary punishment.
D. "The facility's legal team will be contacting you to discuss the incident." Involving legal action for a minor, non-harmful event is excessive and contradicts just culture, which emphasizes education, accountability, and system improvements over legal consequences.
Correct Answer is A
Explanation
A. High-pitched wheezing Wheezing indicates airway constriction, which is a sign of anaphylaxis, a life-threatening allergic reaction. This requires immediate intervention (e.g., stopping the medication, administering epinephrine, and providing oxygen).
B. Urticaria over the entire body While urticaria (hives) is a sign of an allergic reaction, it is not as urgent as airway compromise. It should still be reported but does not take immediate priority over wheezing.
C. Pruritis of the face Facial itching is a mild allergic reaction but does not indicate imminent airway compromise like wheezing does.
D. Rhinitis with clear discharge Nasal congestion or a runny nose can be a mild allergic reaction but is not an emergency.
Priority action: Apply the ABC (Airway, Breathing, Circulation) framework, which prioritizes airway compromise (wheezing) over skin-related allergic reactions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.