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. "Wear compression stockings daily":
Compression stockings are not directly related to preventing the complications of retinopathy and nephropathy in diabetes. They are more commonly recommended for managing conditions like venous insufficiency and preventing blood clots.
B. "Have an eye examination once per year":
While regular eye examinations are important for monitoring and early detection of diabetic retinopathy, maintaining stable blood glucose levels is more directly related to preventing the progression of retinopathy.
C. "Maintain stable blood glucose levels":
This is the correct instruction. Stable blood glucose levels are crucial in preventing and minimizing the long-term complications of diabetes, including retinopathy (damage to the retina) and nephropathy (kidney damage). Consistent blood glucose control is key to reducing the risk of complications.
D. "Examine your feet carefully every day":
Daily foot examinations are essential for preventing diabetic foot complications, including ulcers and infections. While important for overall diabetes management, foot care is not specifically directed at preventing retinopathy and nephropathy.
Correct Answer is B
Explanation
A. Limit fluid intake not related to meals:
While staying hydrated is important, it's generally recommended to limit fluid intake not related to meals to avoid overfilling the stomach and putting excess pressure on the lower esophageal sphincter (LES). However, this is not as specific to GERD management as the option B.
B. Avoid eating within 3 hours of bedtime:
This is a key recommendation for managing GERD. Eating close to bedtime increases the likelihood of stomach contents refluxing into the esophagus when lying down. Waiting at least 3 hours after eating before lying down can help prevent symptoms.
C. Chew on mint leaves to relieve indigestion:
Mint, including mint leaves, can relax the LES, potentially worsening GERD symptoms. It is not recommended for managing GERD.
D. Season foods with black pepper:
While black pepper itself is not a common trigger for GERD, highly spicy or peppery foods can sometimes exacerbate symptoms in individuals with GERD. It's advisable to pay attention to personal triggers and adjust the diet accordingly.
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