A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?

Explain the procedure for an upper gastrointestinal series

Administer pain medication

Assess orthostatic blood pressure

Test the client’s emesis for blood .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice B rationale

Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice C rationale

Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.

Choice D rationale

Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

While altered mucus membranes can occur in patients with Crohn’s disease, it is not typically the primary nursing assessment.

Choice B rationale

Fluid volume deficit can occur in patients with Crohn’s disease due to diarrhea, a common symptom of the disease. However, it is not typically the primary nursing assessment.

Choice C rationale

Nutrition should be prioritized in the nursing assessment for a patient diagnosed with Crohn’s disease. Malnutrition can occur due to decreased appetite, malabsorption of nutrients, and increased nutritional needs due to inflammation.

Choice D rationale

While skin integrity can be a concern in patients with Crohn’s disease, particularly those with fistulas, it is not typically the primary nursing assessment.

A. Ask the client if she has considered harming her newborn. B. Anticipate a prescription by the provider for an antidepressant. C. Assist the family to identify prior use of positive coping skills in family crises. D. Reinforce postpartum and newborn care discharge teaching.

Correct Answer is A

Explanation

Choice A rationale

If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.

Choice B rationale

While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice C rationale

Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice D rationale

Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of caring for a patient diagnosed with Crohn’s disease, which nursing assessment should be prioritized?

Correct Answer is C

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling “down” and sad, having no energy, and wanting to cry.What should be the nurse’s priority action?

Correct Answer is A

Explanation

A nurse is providing care for a patient who the healthcare provider suspects may have pernicious anemia.Which diagnostic test should the nurse anticipate the healthcare provider will order?

A nurse is caring for a client who has just been admitted to the medical-surgical unit from the emergency department.The nurse is reviewing the client’s medical records.Which of the following conditions is the client most likely experiencing, based on the client’s notes and actions to be taken?

A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption.The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is educating a group of patients in their first trimester about exercise during pregnancy.Which of the following statements should the nurse include in the teaching?

A nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.The healthcare provider has been informed.What is the nurse’s priority action?

A nurse is assessing a newborn 1 hour after birth.The nurse recognizes that which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is caring for a patient diagnosed with diabetic ketoacidosis.Which of the following symptoms should the nurse expect?

A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?

A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?