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.

Answer and Explanation

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.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale

Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.

Choice B rationale

Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.

Choice C rationale

Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.

Choice D rationale

Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.

Choice E rationale

Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.

A. Vitamin B supplements. B. Iron supplements. C. Vitamin B12 injections. D. Blood transfusions.

Correct Answer is C

Explanation

Choice A rationale

Vitamin B supplements are not sufficient for treating pernicious anemia, as the condition involves an inability to absorb vitamin B12 from the gastrointestinal tract.

Choice B rationale

Iron supplements are not the primary treatment for pernicious anemia, which is specifically caused by a deficiency in vitamin B1289.

Choice C rationale

Vitamin B12 injections are the correct treatment for pernicious anemia. These injections bypass the gastrointestinal tract and provide the necessary vitamin B12 directly into the bloodstream.

Choice D rationale

Blood transfusions are not typically required for the treatment of pernicious anemia unless there is severe anemia or other complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?

Correct Answer is C

Explanation

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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?