A nurse is collecting data from a client who has anemia due to excess blood loss during surgery causing a decrease in blood flow/perfusion in the patient. The patient's vital signs are as follows: BP 100/60. HR 122. Resp 24, SPO2 92%. The nurse should expect which of the following findings/symptoms?

Dyspnea on exertion

Respiratory depression

Intense abdominal pain

Bradycardia

Answer and Explanation

The Correct Answer is A

A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.

B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.

C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.

D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.

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Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"

Explanation

To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line on the left side of the chest. This is the location of the apex of the heart, also referred to as the point of maximal impulse (PMI).

A. Wrapping the cuff too loosely around the client's arm B. Positioning the client's arm above heart level C. Deflating the cuff too slowly D. Measuring blood pressure right after the client's mealtime

Correct Answer is B

Explanation

A. Wrapping the cuff too loosely around the client's arm: A loosely wrapped cuff can cause an inaccurately high reading, not a low one.

B. Positioning the client's arm above heart level: If the client’s arm is positioned above heart level, the blood pressure reading may be inaccurately low. Blood pressure measurements should always be taken with the arm at heart level.

C. Deflating the cuff too slowly: Deflating the cuff too slowly typically leads to an inaccurately high reading, not a low one.

D. Measuring blood pressure right after the client's mealtime: While digestion can sometimes cause a slight drop in blood pressure, it is not typically a significant factor in obtaining an unusually low reading.

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Naxlex Comprehensive Predictor Exams

A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"

Explanation

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is B

Explanation

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