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 C

Explanation

Choice A rationale

Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.

Choice B rationale

Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.

Choice C rationale

Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.

Choice D rationale

Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.

A. Unilateral joint involvement. B. Ulnar deviation. C. Decreased sedimentation rate. D. Fractures of the spine.

Correct Answer is B

Explanation

Choice A rationale

Unilateral joint involvement is not typical of rheumatoid arthritis. This condition usually affects joints symmetrically, meaning both sides of the body are involved. Rheumatoid arthritis is an autoimmune disorder where the immune system mistakenly attacks the synovium, leading to inflammation and joint damage.

Choice B rationale

Ulnar deviation is a common finding in rheumatoid arthritis. It occurs due to chronic inflammation and damage to the joints, particularly in the hands. The fingers may deviate towards the ulnar side (the side of the little finger) due to the weakening of the ligaments and tendons.

Choice C rationale

Decreased sedimentation rate is not a typical finding in rheumatoid arthritis. In fact, the erythrocyte sedimentation rate (ESR) is usually elevated in this condition due to the ongoing inflammation. ESR is a marker of inflammation and is used to monitor disease activity.

Choice D rationale

Fractures of the spine are not a common finding in rheumatoid arthritis. While osteoporosis can be a complication of rheumatoid arthritis, leading to an increased risk of fractures, the spine is not typically the primary site of joint involvement in this condition.

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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 has cirrhosis. Which of the following is an expected finding for this client?

Correct Answer is C

Explanation

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Correct Answer is B

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?