The nurse is assessing a patient in the immediate post-operative phase. Which of thr following assessment findings would be most indicative of post-operative hemorrhage?

Stow, shallow respirations and low heart rate

Fever and flushed skin

Disorientation and confusion in an elderly patient

Increasing heart rate and decreasing blood pressure

Answer and Explanation

The Correct Answer is D

A. Slow, shallow respirations and low heart rate:
Slow, shallow respirations and a low heart rate are not typical signs of postoperative hemorrhage. These signs might suggest respiratory or cardiac issues, but they are not specific to hemorrhage. In fact, hemorrhage is more likely to result in tachycardia (increased heart rate) and hypotension (low blood pressure) rather than bradycardia (low heart rate). Therefore, this finding is not indicative of post-operative hemorrhage.

B. Fever and flushed skin:
Fever and flushed skin are more commonly associated with infection rather than hemorrhage. After surgery, fever can be a sign of infection, particularly if it occurs 24-48 hours postoperatively. While infection can sometimes cause a rise in heart rate, it does not directly correlate with the symptoms of hemorrhage. Therefore, fever and flushed skin are not the most indicative of hemorrhage in the immediate postoperative phase.

C. Disorientation and confusion in an elderly patient:
Disorientation and confusion in the elderly post-operative patient can be concerning and may be caused by a variety of factors, such as medication side effects, electrolyte imbalances, or postoperative delirium. While confusion can occur with significant blood loss, it is not a primary indicator of hemorrhage. The signs of hemorrhage are more likely to include changes in vital signs, especially heart rate and blood pressure. Therefore, while disorientation and confusion should be monitored, they are not the most definitive sign of hemorrhage.

D. Increasing heart rate and decreasing blood pressure:
Increasing heart rate (tachycardia) and decreasing blood pressure (hypotension) are classic signs of hemorrhage. When blood loss occurs, the body compensates by increasing the heart rate to maintain cardiac output and attempting to constrict blood vessels. As hemorrhage progresses, blood volume decreases, which leads to a drop in blood pressure. This combination of tachycardia and hypotension is a key indicator of significant blood loss and requires immediate assessment and intervention. Therefore, this is the most indicative finding of postoperative hemorrhage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Nitrofurantoin (Macrobid): While nitrofurantoin is commonly prescribed for urinary tract infections (UTIs), it does not typically cause a red-orange discoloration of the urine. Nitrofurantoin may cause other side effects, such as gastrointestinal upset or pulmonary issues, but urine discoloration is not a common or expected side effect.

B) Sulfamethoxazole-trimethoprim (SMX TMP, Bactrim): Sulfamethoxazole-trimethoprim is another common medication for UTIs, but it does not cause urine to turn red-orange. Some individuals may experience allergic reactions, rash, or gastrointestinal side effects, but urine discoloration is not typically associated with this medication.

C) This is expected with a UTI not related to medications: While it’s true that UTIs can cause changes in urine color due to blood or infection, the red-orange discoloration specifically linked to a UTI is often caused by medications, not the infection itself. Therefore, this statement is not accurate in explaining the cause of the urine color change.

D) Phenazopyridine (Pyridium): This is the correct answer. Phenazopyridine is a medication commonly used to alleviate urinary tract pain and discomfort. One of its well-known side effects is causing urine to turn a red-orange color. This discoloration is harmless and typically resolves once the medication is discontinued. However, patients should be informed about this effect to avoid unnecessary concern.

A. Encourage strict bed rest with tuning and repositioning every 2 hours. B. Have the client dangle" their legs several times per day and when pain occurs, C. Have the client elevate their legs above heart level when pain occurs D. Have the client use ice packs to relieve lower extremity pain.

Correct Answer is B

Explanation

A) "Encourage strict bed rest with turning and repositioning every 2 hours":
. For clients with peripheral arterial disease (PAD), strict bed rest is not recommended unless the client is in severe pain or experiencing complications like ulcers or gangrene. In PAD, exercise and mobility are essential for improving blood flow and reducing symptoms. Prolonged immobility could worsen circulation and lead to complications like muscle atrophy. Therefore, encouraging gentle movement and activity, like walking or repositioning, is typically more beneficial than prolonged bed rest.

B) "Have the client 'dangle' their legs several times per day and when pain occurs":
. For clients with PAD, dangling the legs can be helpful in alleviating pain and discomfort. When the client dangles their legs, gravity helps to increase blood flow to the lower extremities, which can provide temporary relief from symptoms like intermittent claudication (pain caused by insufficient blood flow). It is important to balance this with the advice to avoid elevating the legs, as elevating them above the heart level may decrease arterial perfusion, worsening symptoms.

C) "Have the client elevate their legs above heart level when pain occurs":
. Elevating the legs above the heart level in clients with PAD may worsen symptoms. In PAD, blood flow to the legs is already compromised, and elevating the legs above the heart can further reduce arterial blood flow to the lower extremities, increasing pain and discomfort. Instead, dangling the legs or lying flat with the legs at heart level is generally better for improving circulation.

D) "Have the client use ice packs to relieve lower extremity pain":
. Applying ice packs is not recommended for clients with PAD, as cold can cause vasoconstriction, further reducing blood flow to already compromised tissues. Cold therapy may increase pain and lead to tissue damage in individuals with reduced circulation. The nurse should instead focus on strategies that promote blood flow, such as encouraging gentle exercise, dangling the legs, or using warmth (in some cases) to improve circulation.

View Question and Answer

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

The nurse is assessing a patient in the immediate post-operative phase. Which of thr following assessment findings would be most indicative of post-operative hemorrhage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who following prescribed multiple medications for recurring urinary tract infections tells the nurse that her urine has turned red-orange. Which of the following prescribed medications does the nurse suspect is responsible for this change?

Correct Answer is D

Explanation

A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

An older adult client presents with dyspnea on exertion, cough with green sputum, fever, and fatigue. The nurse notes thick rhonchi/coarse crackles upon lung auscultation and the patient's chest X-ray shows bilateral consolidation. The nurse anticipates which of the following interventions?

The nurse is monitoring the effectiveness or antiretroviral therapy (ART) for a patient with human immunodeficiency virus (HIV). What laboratory study results indicates the medications are effective?

The nurse recognizes which of the following as signs and symptoms of hyperglycemia type I diabetes mellitus? Select all that apply,

You are assessing a client admitted from a long-term care facility. When noting a stage Il pressure injury on the client's coccyx, which of the following would you expect?

A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

A nurse is preparing to give routine medications to a client with a history of hypertension. The nurse recognizes the need to assess the clients blood pressure before and after administering which of the following medications?