A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?

Explain the procedure for an upper gastrointestinal series

Administer pain medication

Assess orthostatic blood pressure

Test the client’s emesis for blood .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice B rationale

Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice C rationale

Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.

Choice D rationale

Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

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Correct Answer is B

Explanation

Choice A rationale

Epigastric discomfort is a common symptom of peptic ulcer disease, but it is not typically the symptom that should be prioritized. While discomfort can indicate an active ulcer, it does not necessarily signify a complication.

Choice B rationale

Hematemesis, or vomiting blood, is a serious symptom that could indicate a bleeding ulcer, which is a medical emergency. Therefore, this symptom should be prioritized.

Choice C rationale

Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease. However, it is not typically the symptom that should be prioritized as it does not necessarily indicate a serious complication.

Choice D rationale

Constipation is not typically associated with peptic ulcer disease and therefore should not be prioritized.

A. Passenger B. Passageway C. Powers D. Position .

Correct Answer is B

Explanation

Choice A rationale

The term “passenger” in the context of the 5 P’s of labor refers to the fetus. The size, presentation, and position of the fetus can all affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the fetus, so this is not the correct answer.

Choice B rationale

The term “passageway” refers to the birth canal, which includes the pelvis. The size and shape of the pelvis can greatly impact the progress of labor. If the provider comments that there is “plenty of room in the pelvis,” they are likely referring to the passageway. Therefore, this is the correct answer.

Choice C rationale

The term “powers” refers to the contractions during labor. The frequency, duration, and intensity of contractions can affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to contractions, so this is not the correct answer.

Choice D rationale

The term “position” refers to the mother’s position during labor. Different positions can help facilitate the progress of labor and can help with pain management. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the mother’s position, so this is not the correct answer.

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A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating a patient who has been diagnosed with peptic ulcer disease.Which symptom should the nurse prioritize?

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A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?