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

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

A. Increased appetite. B. Nausea. C. Increased energy level. D. Seeing halos around bright objects. E. Photophobia.

Correct Answer is ["B","D","E"]

Explanation

Choice B rationale

Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can lead to gastrointestinal disturbances, including nausea, vomiting, and loss of appetite.

Choice D rationale

Seeing halos around bright objects is a classic sign of digoxin toxicity. This visual disturbance, along with blurred vision and yellow-green vision, indicates that the digoxin level is too high.

Choice E rationale

Photophobia, or sensitivity to light, can also be a symptom of digoxin toxicity. This occurs due to the effects of digoxin on the visual system.

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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 in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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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?