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. Administer medications:
While nasogastric tubes can be used to administer medications, this is not the primary rationale for their use in pyloric obstruction. The primary goal is often decompression.
B. Supply nutrients via tube feedings:
Providing nutrients via tube feedings is not the primary purpose in the context of a pyloric obstruction. Decompression is more relevant in this scenario.
C. Decompress the stomach:
Decompressing the stomach is a common use of nasogastric tubes in the context of pyloric obstruction. The tube helps to remove excess air and gastric contents, relieving pressure in the stomach.
D. Determine the pH of the gastric secretions:
While determining the pH of gastric secretions is a possible use, it is not the primary rationale for nasogastric tube placement in pyloric obstruction. The primary goal is often to relieve obstruction and decompress the stomach.
Correct Answer is ["A","B","C","D"]
Explanation
A. Increase physical activity and daily exercise.
Regular physical activity helps improve insulin sensitivity, manage blood glucose levels, and lower the risk of cardiovascular complications associated with diabetes.
B. Reduce cholesterol and saturated fat intake.
Managing cholesterol levels and reducing saturated fat intake can help lower the risk of cardiovascular disease, which is a common complication of diabetes.
C. Maintain optimal blood pressure to prevent kidney damage.
Controlling and maintaining blood pressure within optimal ranges is crucial in preventing kidney damage, a common complication of diabetes.
D. Enroll in a smoking-cessation program.
Smoking increases the risk of cardiovascular complications and can exacerbate other diabetes-related health issues. Quitting smoking is important in reducing the risk of complications.
E. Sustain hyperglycemia to reduce deterioration of nerve cells.
Sustaining hyperglycemia (high blood sugar levels) is detrimental and contributes to the progression of diabetic complications, including nerve damage (neuropathy). Lowering and controlling blood glucose levels are essential in preventing complications rather than sustaining hyperglycemia.
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