A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours.
What will the triage nurse do first?

Insert a nasogastric (NG) tube.

Ask the client about the precipitating events.

Obtain vital signs.

Complete a head-to-toe assessment.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.

Choice B rationale

Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.

Choice C rationale

Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.

Choice D rationale

Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.

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Correct Answer is ["B","C","E","F","G"]

Explanation

Choice A rationale

Potassium level is not directly related to wound healing. While potassium is essential for overall cellular function, it does not have a direct impact on the wound healing process.

Choice B rationale

Pre-albumin level is a marker of nutritional status. Low pre-albumin levels indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for the synthesis of collagen and other proteins involved in the wound healing process.

Choice C rationale

History of diabetes mellitus can significantly delay wound healing. High blood glucose levels can impair immune function, reduce blood flow, and increase the risk of infection, all of which can delay the healing process.

Choice D rationale

History of hyperlipidemia is not directly related to wound healing. While hyperlipidemia can contribute to other health issues, it does not have a direct impact on the wound healing process.

Choice E rationale

Wound infection is a major factor that can delay wound healing. Infection can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.

Choice F rationale

Decreased pedal perfusion indicates poor blood flow to the extremities. Adequate blood flow is essential for delivering oxygen and nutrients to the wound site, and poor perfusion can delay the healing process.

Choice G rationale

Fasting blood glucose levels are an indicator of blood sugar control. High fasting blood glucose levels can impair immune function and increase the risk of infection, both of which can delay wound healing.

A. Remove the vest daily to inspect the client’s skin integrity. B. Check that the halo jacket is snug against the client’s skin. C. Provide range of motion to the client’s neck. D. Monitor the client for an elevated temperature.

Correct Answer is D

Explanation

Choice A rationale

Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.

Choice B rationale

The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.

Choice C rationale

Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.

Choice D rationale

Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.

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A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Select the 5 findings that can cause delayed wound healing.

Correct Answer is ["B","C","E","F","G"]

Explanation

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?

The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?

A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?

A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours.
What will the triage nurse do first?