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 D

Explanation

According to the Rule of Nines, the percentage of body surface area for different parts of the body is calculated to estimate burn severity. For example, the anterior and posterior aspects of each leg account for 18% each, and the back accounts for 18%. Therefore, the total body surface area burned can be estimated based on these percentages.

A. The client develops a life-threatening situation. B. The client has to be repositioned in the bed. C. The client complains of pain. D. The client needs to have an x-ray of the femur performed.

Correct Answer is A

Explanation

Choice A rationale

The weights from the traction device should only be removed if the client develops a life- threatening situation. This is to ensure the client’s immediate safety and address the critical condition.

Choice B rationale

The client should not have the weights removed for repositioning in the bed. Proper techniques should be used to reposition the client without removing the weights to maintain the effectiveness of the traction.

Choice C rationale

Complaints of pain should be addressed by assessing the cause and providing appropriate pain management, but the weights should not be removed as it can compromise the traction.

Choice D rationale

The weights should not be removed for an x-ray. The traction can be maintained during imaging procedures to ensure continuous treatment.

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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 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?

Correct Answer is D

Explanation

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?

Correct Answer is A

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?