A client with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first?

Check BP, heart rate and respirations

Insert two large-gauge IV catheters

Draw blood for coagulation studies

Place the client in the prone position

Answer and Explanation

The Correct Answer is A

A. Check BP, heart rate and respirations: Assessing vital signs is the first action because the client is at high risk for hypovolemic shock due to acute blood loss from gastrointestinal bleeding. Early recognition of hemodynamic instability allows the nurse to prioritize interventions such as fluid resuscitation and oxygen therapy. Rapid assessment ensures timely detection of life-threatening changes.

B. Insert two large-gauge IV catheters: Establishing IV access is critical for fluid and blood replacement, but it follows the initial assessment of the client’s hemodynamic status. Knowing the client’s blood pressure and heart rate guides the urgency and volume of resuscitation needed. IV insertion is essential but is not the first immediate action.

C. Draw blood for coagulation studies: Coagulation studies provide important baseline data and help guide treatment of bleeding tendencies in cirrhosis. However, these results are not immediately available, and drawing blood does not address the acute risk of hypovolemic shock. Stabilizing the client comes before diagnostic testing.

D. Place the client in the prone position: The prone position does not benefit a client who is actively vomiting blood and may worsen airway protection. Instead, the client should be positioned to maintain airway patency, typically with the head of the bed elevated. Airway management may be necessary, but vital signs assessment remains the priority first step.

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Correct Answer is A

Explanation

A. 36%: Using the Rule of Nines, the anterior trunk accounts for 18%, and the anterior surfaces of both legs account for 9% each (total 18%). Combined, this equals 36% TBSA burned. This calculation guides fluid resuscitation and predicts burn severity.

B. 30%: This undervalues the total burn area and does not align with the standardized Rule of Nines. Both legs alone contribute 18%, and adding the anterior trunk must total 36%, not 30%.

C. 27%: This figure does not correspond to any combination of major body surface segments defined by the Rule of Nines. It omits a portion of the affected areas and underestimates the injury extent.

D. 18%: This represents only the anterior trunk or both anterior legs, not the combined total. It significantly underestimates the actual burned surface area and would lead to inadequate fluid resuscitation.

A. The client has likely developed a systemic infection. B. The client is likely experiencing an anaphylactic reaction to a medication. C. The client's respiratory complications are likely related to psychosocial stress. D. The client is likely experiencing a delayed onset of respiratory complications.

Correct Answer is D

Explanation

A. The client has likely developed a systemic infection: Systemic infections typically develop later in the course of burn injuries, often after the first 48–72 hours, and present with fever, tachycardia, and other systemic signs. While infection is a concern, it is less likely to explain acute airway obstruction at 36 hours post-burn.

B. The client is likely experiencing an anaphylactic reaction to a medication: Anaphylaxis usually occurs immediately or shortly after exposure to an allergen or new medication. The delayed development of airway obstruction 36 hours after burn injury makes anaphylaxis less likely.

C. The client's respiratory complications are likely related to psychosocial stress: Psychological stress can affect breathing patterns, but it does not cause physical airway obstruction or progressive respiratory compromise. The client’s airway changes are physiological rather than psychosocial in origin.

D. The client is likely experiencing a delayed onset of respiratory complications: Inhalation injuries can cause progressive airway edema that worsens hours after the initial burn. Swelling of the upper airway and bronchial mucosa can lead to obstruction, making this a delayed but serious respiratory complication that requires immediate intervention.

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A client with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the emergency department with partial-thickness and full-thickness burns on the anterior surface of both legs and anterior trunk. Using the Rule of Nines what is the total body surface area that has been burned?

Correct Answer is A

Explanation

A nurse on a burn unit is caring for a client who experienced burn injuries 36 hours ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?

Correct Answer is D

Explanation

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