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 D

Explanation

Choice A rationale

Vitamin K is not the antidote for heparin. It is used to reverse the effects of warfarin, which is a vitamin K antagonist.

Choice B rationale

Iron is not related to the reversal of heparin. It is a mineral that is crucial for many bodily functions, including the transport of oxygen in the blood.

Choice C rationale

Glucagon is a hormone that raises the level of glucose in the blood. It is not used as an antidote for heparin.

Choice D rationale

Protamine is the correct choice. Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it and forming a stable complex, thereby neutralizing its anticoagulant activity.

A. Impaired carbon dioxide elimination due to shunting. B. Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch. C. Hypoxemia due to dead space. D. Decreased pulmonary compliance due to stiffness.

Correct Answer is ["A","D"]

Explanation

Choice A rationale

In ARDS, impaired carbon dioxide elimination due to shunting can occur. Shunting refers to the diversion of blood from areas of the lung that are ventilated to areas that are not, leading to impaired gas exchange.

Choice B rationale

Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is not a typical finding in ARDS3.

Choice C rationale

Hypoxemia due to dead space is not a typical finding in ARDS. Dead space refers to areas of the lung that are ventilated but not perfused.

Choice D rationale

Decreased pulmonary compliance due to stiffness is a typical finding in ARDS. The lungs become stiff and less compliant due to the accumulation of fluid and inflammatory cells in the alveoli and interstitial space.

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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

A nurse is caring for a patient who is receiving heparin by continuous IV infusion.Which of the following medications should the nurse plan to administer in the event of an overdose?

Correct Answer is D

Explanation

A nurse is assessing a patient who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

Correct Answer is ["A","D"]

Explanation

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