A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours.
What will the triage nurse do first?
Insert a nasogastric (NG) tube.
Ask the client about the precipitating events.
Obtain vital signs.
Complete a head-to-toe assessment.
The Correct Answer is C
Choice A rationale
Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.
Choice B rationale
Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.
Choice C rationale
Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.
Choice D rationale
Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering diphenhydramine with food does not specifically address the adverse effect of dry mouth. While taking the medication with food can help reduce gastrointestinal side effects, it does not alleviate dry mouth.
Choice B rationale
Chewing on sugarless gum or sucking on hard candies can help stimulate saliva production and alleviate dry mouth. This is an effective and simple measure to manage the adverse effect of dry mouth associated with diphenhydramine.
Choice C rationale
Placing a humidifier at the bedside can help maintain moisture in the air, but it is not the most effective measure for managing dry mouth. Chewing gum or sucking on candies directly stimulates saliva production, providing more immediate relief.
Choice D rationale
Discontinuing the medication and notifying the provider is not necessary for managing dry mouth. Dry mouth is a common and manageable side effect of diphenhydramine. Simple measures like chewing gum or sucking on candies are usually sufficient to alleviate this symptom
Correct Answer is A
Explanation
Choice A rationale
Eating a high fiber diet will reduce my risk for developing skin cancer. This statement is incorrect because a high fiber diet has not been proven to reduce the risk of developing skin cancer. Skin cancer is primarily caused by exposure to ultraviolet (UV) radiation from the sun or artificial sources like tanning booths.
Choice B rationale
I should check my skin monthly for any changes. This statement is correct. Regular self- examinations can help detect skin cancer early when it is most treatable. The American Academy of Dermatology recommends checking your skin from head to toe every month.
Choice C rationale
I should avoid the use of tanning booths. This statement is correct. Tanning booths emit UV radiation, which increases the risk of developing skin cancer. Avoiding tanning booths is a crucial preventive measure.
Choice D rationale
I should use sunscreen even on cloudy days. This statement is correct. UV rays can penetrate clouds, so it is essential to use sunscreen every day, regardless of the weather, to protect the skin from harmful UV radiation.
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