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

Explanation

Choice A rationale

Hypervolemia is not typically associated with extensive burn injuries. Burn patients often experience hypovolemia due to fluid loss from the burn wounds.

Choice B rationale

Hyperkalemia is a common finding in patients with extensive burn injuries. The destruction of cells releases potassium into the bloodstream, leading to elevated potassium levels.

Choice C rationale

Low hemoglobin is not a typical finding in the initial phase of burn injury. Hemoglobin levels may decrease later due to blood loss or hemodilution.

Choice D rationale

Metabolic alkalosis is not commonly associated with extensive burn injuries. Burn patients are more likely to experience metabolic acidosis due to tissue hypoxia and lactic acid accumulation.

A. Check the circulation of the affected extremity. B. Administer additional pain medication. C. Reposition the affected extremity. D. Document the findings.

Correct Answer is A

Explanation

Choice A rationale

Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.

Choice B rationale

Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.

Choice C rationale

Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.

Choice D rationale

Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious 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 in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is A

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?