Question

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate of 80/min, BP 130/70, respiratory rate of 16/min, temperature 36°C/ 96.8°F. Which of the following vital sign changes should alert the nurse that the patient might be hemorrhaging?

a) Heart rate of 88/min
b) BP 140/80
c) Respiratory rate of 20/min
d) Temperature of 37°C/ 98.6°F

Answer 1

A decrease in blood pressure (BP) to 140/80 should alert the nurse that the patient might be hemorrhaging.

Step-by-step explanation:

The vital sign change that should alert the nurse that the patient might be hemorrhaging is a decrease in blood pressure (BP) to 140/80. A decrease in BP can indicate blood loss and decreased perfusion to the body's organs. The other vital sign changes listed - an increase in heart rate (HR) to 88/min, an increase in respiratory rate (RR) to 20/min, and a slight increase in body temperature to 37°C/ 98.6°F - are all within normal ranges and may not necessarily indicate hemorrhaging.