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.
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Related Questions
Correct Answer is D
Explanation
A. Applying a cold pack to the client's upper arm is not the first action. The priority is to assess and address the cause of the edema. Cold packs may be used for comfort, but they do not address the underlying issue.
B. Removing the PICC line is not the first action. Before considering removal, it is essential to assess the extent and cause of the edema. Removing the line without proper evaluation could lead to premature discontinuation of necessary treatment.
C. Notifying the provider who inserted the PICC line is important, but it is not the first action. The nurse needs to assess and intervene promptly. The provider should be informed after initial actions are taken.
D. Stopping the infusion and measuring the circumference of both upper arms is the first action. This helps determine the extent of the edema and whether it is related to the infusion. It is crucial to assess for complications such as infiltration or extravasation of the TPN solution.
Correct Answer is A
Explanation
A. Regular insulin:
Regular insulin, also known as short-acting insulin, is commonly used in the initial management of diabetic ketoacidosis. It has a relatively rapid onset of action, making it suitable for addressing the acute and severe nature of DKA.
B. Insulin detemir:
Insulin detemir is a long-acting insulin analog. It is not the preferred choice for addressing the acute insulin needs in DKA; instead, it is used for basal insulin requirements in the maintenance phase of diabetes management.
C. Insulin glargine:
Insulin glargine is a long-acting insulin analog used for basal insulin coverage. Like insulin detemir, it is not the first choice for addressing the acute insulin needs in the initial treatment of DKA.
D. NPH insulin:
NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin. While it has a role in diabetes management, it is not the preferred choice for the initial treatment of DKA. NPH insulin has a slower onset and longer duration compared to regular insulin.
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