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 C
Explanation
Choice A rationale
Friction rub is not a typical complication of endocarditis. It is more commonly associated with pericarditis, which is inflammation of the pericardium.
Choice B rationale
Intermittent claudication is not a complication of endocarditis. It is typically associated with peripheral artery disease, which affects blood flow to the limbs.
Choice C rationale
Cardiac murmur is a common finding in endocarditis. The infection can cause damage to the heart valves, leading to abnormal heart sounds or murmurs.
Choice D rationale
Dependent rubor is not a complication of endocarditis. It is usually associated with peripheral artery disease and is characterized by redness of the lower extremities when they are in a dependent position.
Correct Answer is C
Explanation
Choice A rationale
Pancreatic pseudocyst is a complication of acute pancreatitis, but it is not directly associated with Cullen’s sign. Cullen’s sign indicates periumbilical ecchymosis, which is a sign of internal bleeding.
Choice B rationale
Electrolyte imbalance can occur in acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign specifically points to internal bleeding.
Choice C rationale
Internal bleeding is the correct answer. Cullen’s sign is a bluish discoloration around the umbilicus, indicating bleeding within the abdomen. This can occur in severe cases of acute pancreatitis due to hemorrhage.
Choice D rationale
Pleural effusion can be a complication of acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign is specific to internal bleeding.
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