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 A
Explanation
A. Cheddar cheese:
Cheddar cheese is high in fat, and individuals with a history of pancreatitis are often advised to limit their fat intake. High-fat foods can stimulate the pancreas to release digestive enzymes, potentially triggering or exacerbating pancreatitis.
B. Vegetable soup:
Depending on the ingredients, vegetable soup may or may not be high in fat. The key consideration is to choose soups that are not prepared with excessive amounts of fat or oil.
C. Noodles:
Noodles, by themselves, are not high in fat. However, the choice of sauce or toppings can impact the overall fat content of the meal. It's important to consider the entire composition of the dish.
D. Baked fish:
Baked fish is generally a lean protein source and is lower in fat compared to some other protein sources. Baked fish is often considered a suitable choice for individuals with a history of pancreatitis.
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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