A nurse is monitoring a client for potential hemorrhage after a medical procedure. Which vital sign change is an early indicator of internal bleeding?

Hypertension

Bradycardia

Tachypnea

Hyperthermia

Answer and Explanation

The Correct Answer is C

A. Hypertension is not an early sign of hemorrhage; instead, hypotension occurs as blood loss progresses.
B. Bradycardia is not an expected response; tachycardia is more common due to compensatory mechanisms.
C. Tachypnea is an early indicator of internal bleeding as the body attempts to compensate for decreased oxygen delivery by increasing respiratory rate.
D. Hyperthermia is not associated with hemorrhage; instead, hypothermia can occur with significant blood loss.

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Correct Answer is B

Explanation

A) Incorrect. Bright red blood in the stool typically indicates lower gastrointestinal bleeding, such as from hemorrhoids or anal fissures.

B) Correct. A tarry and sticky appearance of the stool, also known as melena, is characteristic of upper gastrointestinal bleeding. The dark color is due to the digestion of blood in the stomach.

C) Incorrect. A yellowish color of the stool is not associated with gastrointestinal bleeding. It can be related to other factors like diet or liver issues.

D) Incorrect. Clay-colored stools are pale and occur with problems in the biliary system, not with gastrointestinal bleeding.

A. Encourage the client to ambulate frequently. B. Administer prophylactic antibiotics as prescribed. C. Apply pressure dressings to potential bleeding sites. D. Monitor the client's blood glucose levels.

Correct Answer is C

Explanation

A) Incorrect. While ambulation is important for overall health, it is not the priority action to prevent bleeding complications.

B) Incorrect. Prophylactic antibiotics may be prescribed for specific medical conditions but are not the primary intervention to prevent hemorrhage.

C) Correct. Applying pressure dressings to potential bleeding sites is the priority action to prevent or control bleeding. It helps promote hemostasis and reduces the risk of excessive bleeding.

D) Incorrect. Monitoring blood glucose levels is important for clients with diabetes but is not directly related to preventing hemorrhage.

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A nurse is monitoring a client for potential hemorrhage after a medical procedure. Which vital sign change is an early indicator of internal bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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