The nurse is providing care to a patient in the post anesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure. Which assessment finding correlates to this postoperative complication?
Hypertension
Hypothermia
Tachycardia
Bradypnea
The Correct Answer is C
A. Hypertension: Blood loss leads to hypovolemia, which usually causes hypotension, not hypertension.
B. Hypothermia: While hypothermia can occur postoperatively, it is not the most direct result of blood loss.
C. Tachycardia: Blood loss leads to decreased circulating volume, triggering tachycardia as a compensatory response to maintain oxygen delivery.
D. Bradypnea: Severe blood loss is more likely to cause tachypnea (rapid breathing) rather than slow respirations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Seeking a tutor for help with a challenging class: Seeking help for academic difficulties is a positive coping mechanism, not a warning sign of suicide.
B. Volunteering to serve food at a homeless shelter over the holidays: Volunteering is generally a sign of social engagement and purpose, which lowers suicide risk.
C. Making plans to go to a high school dance: Engaging in social activities is a protective factor against suicide, not a warning sign.
D. Displaying extreme mood swings: Sudden, extreme mood changes, especially from depression to euphoria, can be a warning sign of suicidal ideation.
Correct Answer is C
Explanation
A. Verifying the information with the patient's family members at the bedside: While family members can provide insight, the most critical step is gathering information directly from the patient about the reaction.
B. Placing an alert bracelet on the patient before leaving the unit: While this is necessary, the nurse should first confirm the details of the allergy.
C. Asking the patient to describe the reaction that occurs: The nurse must determine whether the reaction is a true allergy (e.g., anaphylaxis, rash, difficulty breathing) or an intolerance (e.g., nausea, drowsiness). This ensures appropriate precautions are taken.
D. Documenting the information on the patient's medical record: Documentation is crucial but should follow verification of the allergy details.
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