A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800.
After checking the patient’s morning glucose level, what action should the nurse take?

Choice A rationale

Vitamin K is used to reverse the effects of warfarin. Warfarin is an anticoagulant that works by inhibiting the synthesis of vitamin K-dependent clotting factors. When the INR is too high, indicating a high risk of bleeding, vitamin K can be administered to increase the production of clotting factors and reduce the risk.

Choice A rationale

Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice B rationale

Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice C rationale

Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.

Choice D rationale

Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.