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.

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Correct Answer is C

Explanation

A) Instruct the patient to swallow the medication with the head tilted backwards:
Tilting the head backward while swallowing may worsen the patient's ability to swallow, especially if they are experiencing facial droop and slurred speech. This position could increase the risk of aspiration or choking. A safer approach involves evaluating the patient’s swallowing ability before giving any oral medications.

B) Place the medication in the back of the mouth on the affected side:
While placing the medication on the unaffected side might seem like an alternative to help with swallowing, it is still important to assess the patient's swallowing ability first. If the patient has difficulty swallowing due to neurological deficits, placing the medication on the affected side could increase the risk of aspiration, leading to complications such as pneumonia.

C) Evaluate the patient’s ability to swallow:
Evaluating the patient's ability to swallow is the most important initial action. Facial droop and slurred speech can indicate potential dysphagia or difficulty swallowing, which could lead to aspiration if medications are given orally without further assessment. The nurse must determine if the patient can swallow safely before administering any oral medications, including aspirin, to prevent complications.

D) Provide the patient with thickened liquids:
Thickened liquids may be helpful for patients with known dysphagia, but this approach is not suitable in this case because the first priority is assessing the patient's swallowing ability. Giving thickened liquids without evaluating swallowing could increase the risk of aspiration if the patient is unable to manage liquids safely. An evaluation should precede any interventions like thickening liquids.

A. Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification B. Ensuring that the client signed a consent form for receiving blood transfusions beforehand C. Preparing a primary and secondary IV tubing D. Obtaining a bag of 0.9% sodium chloride

Correct Answer is C

Explanation

A) Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification:
Two registered nurses must independently verify that the blood product matches the patient's identification and that it is properly labeled. This is a critical safety measure to prevent errors, such as mismatched blood transfusions, which can lead to severe complications like hemolytic reactions. Proper verification before administration is a standard safety protocol in blood transfusion procedures.

B) Ensuring that the client signed a consent form for receiving blood transfusions beforehand:
Obtaining informed consent is a vital legal and ethical step before administering a blood transfusion. The nurse must ensure that the patient understands the potential risks and benefits of the procedure and has signed a consent form prior to transfusion. Without consent, the transfusion cannot legally be performed. This is a key part of patient rights and nursing responsibilities.

C) Preparing a primary and secondary IV tubing:
For blood transfusions, only blood administration tubing should be used, which typically includes a filter to prevent the infusion of any debris or clots. Using regular IV tubing (primary and secondary) for blood administration is not recommended, as it may not have the necessary filter and could potentially introduce contaminants. Blood should always be administered with tubing specifically designed for that purpose.

D) Obtaining a bag of 0.9% sodium chloride:
Normal saline is typically used as the solution to flush the IV line before and after the transfusion. It is compatible with blood products and helps to prevent clotting or reactions in the line. This is an essential step to ensure safe and effective blood administration.

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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?

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