A nurse is caring for a patient who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

Assess orthostatic blood pressure.

Administer pain medication.

Explain the procedure for an upper gastrointestinal series.

Test the patient’s emesis for blood.

Answer and Explanation

The Correct Answer is A

The first action the nurse should take when caring for a patient with gastrointestinal bleeding is to assess orthostatic blood pressure. This can help determine the extent of the patient’s blood loss and whether they are experiencing hypovolemia.

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Correct Answer is B

Explanation

Choice A rationale

Lower quadrant pain is a common symptom of many conditions, including ectopic pregnancy. However, it does not specifically indicate the presence of blood in the peritoneum.

Choice B rationale

Cullen’s sign, which is the appearance of bruising in the skin around the umbilicus, is a sign of blood in the peritoneum. It can occur in conditions such as a ruptured ectopic pregnancy.

Choice C rationale

Goodell’s sign is a softening of the cervix that typically occurs early in pregnancy. It does not indicate the presence of blood in the peritoneum.

Choice D rationale

Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia that occurs in early pregnancy. It does not indicate the presence of blood in the peritoneum.

A. “Use soap and water to clean the catheter after each use.”. B. “Hold the penis at a 30 to 45-degree angle when inserting the catheter.”. C. “Perform catheterization when you feel the urge to void.”. D. “Inflate the balloon when the urine flow stops.”.

Correct Answer is A

Explanation

Choice A rationale

Cleaning the catheter after each use with soap and water is a crucial step in preventing infection during self-catheterization.

Choice B rationale

The angle at which the penis should be held during catheter insertion can vary, but a 30 to 45- degree angle is not typically recommended.

Choice C rationale

Performing catheterization when feeling the urge to void is not typically part of the instructions for clean intermittent self-catheterization.

Choice D rationale

Inflating the balloon when the urine flow stops is not a step in clean intermittent self- catheterization. This step is associated with indwelling catheters, not intermittent catheters.

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A nurse is caring for a patient who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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