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 .
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.
Choice B rationale
Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.
Choice C rationale
While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.
Choice D rationale
Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.
Correct Answer is A
Explanation
Choice A rationale
Decreased muscle mass is a common age-related musculoskeletal change. As people age, they tend to lose muscle mass due to changes in muscle fiber and decreased physical activity. This can lead to weakness and decreased mobility.
Choice B rationale
Thickened vertebral disks are not typically an age-related change. Instead, the disks often become thinner and less flexible with age, which can lead to conditions like degenerative disk disease.
Choice C rationale
Increased force of isometric contraction is not an age-related musculoskeletal change. In fact, both isometric and isotonic muscle strength tend to decrease with age.
Choice D rationale
Reduced chest width is not typically an age-related musculoskeletal change. However, changes in posture and spinal curvature can affect the shape and function of the chest.
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