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

Choice A rationale

Hyperglycemia, or high blood sugar, is a condition that is most commonly seen in individuals with diabetes. Symptoms can include frequent urination, increased thirst, and increased hunger. If left untreated, it can lead to serious complications such as diabetic ketoacidosis.

Choice B rationale

Anemia is a condition characterized by a decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen. Symptoms can include fatigue, weakness, pale or yellowish skin, irregular heartbeats, shortness of breath, dizziness or lightheadedness, and chest pain.

Choice C rationale

Type 1 diabetes mellitus is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn’t make enough insulin.

Choice D rationale

Hypertension, or high blood pressure, is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. If the nurse is reviewing the client’s medical records and actions to be taken, it is likely that the client is experiencing hypertension.

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.