A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first?
Test the client's emesis for blood.
Assess orthostatic blood pressure.
Explain the procedure for an upper gastrointestinal series.
Administer pain medication.
The Correct Answer is B
A. Testing the client's emesis for blood is an important assessment, but assessing orthostatic blood pressure is a priority. Orthostatic blood pressure measurement helps identify if the client is experiencing significant blood loss, as changes in blood pressure upon standing may indicate hypovolemia.
B. Assessing orthostatic blood pressure is the priority action. Orthostatic hypotension can be a sign of decreased circulating blood volume, which is a concern in clients with gastrointestinal bleeding.
C. Explaining the procedure for an upper gastrointestinal series is not the first priority. While diagnostic tests may be needed, addressing the immediate concern of potential hypovolemia takes precedence.
D. Administering pain medication is not the first action. The priority is to assess and address the potential complications of gastrointestinal bleeding, such as hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clean the peristomal skin four times a day:
While keeping the peristomal skin clean is essential, cleaning it four times a day might be excessive and could lead to skin irritation. Typically, cleansing the area when changing the pouch or as needed is sufficient.
B. Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal:
Applying gentle pressure upon application can assist in securing the seal, but the duration might vary based on the manufacturer's recommendations. It's important not to overly press or manipulate the barrier excessively, as it could cause skin trauma.
C. Empty the pouch when it is 1/3 full:
This is the correct advice. Regularly emptying the pouch prevents leakage and ensures the pouch does not become too heavy or cause skin irritation from weight or pressure.
D. Expect firm fecal content:
With an ileostomy, the fecal content tends to be more liquid compared to other types of ostomies like colostomies, so expecting firm fecal content might not be accurate for this situation.
Correct Answer is D
Explanation
A. COPD (Chronic Obstructive Pulmonary Disease) is not directly associated with acute pancreatitis. The common risk factors for acute pancreatitis include gallstones, alcohol use, and certain medications.
B. Hypolipidemia (low blood lipid levels) is not a typical factor associated with acute pancreatitis. Elevated levels of lipids in the blood (hyperlipidemia) can be a risk factor, but hypolipidemia is not commonly linked to pancreatitis.
C. Diabetes mellitus, while not a direct cause of acute pancreatitis, can be associated with an increased risk. Uncontrolled diabetes may contribute to the development of pancreatitis, but it is not a primary risk factor.
D. Gallstones are a significant risk factor for acute pancreatitis. Gallstones can obstruct the pancreatic duct, leading to inflammation and damage to the pancreas. This obstruction is one of the common causes of acute pancreatitis.
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