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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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of maintenance IV infusion is not the first action the nurse should take when observing that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. This pattern is known as late decelerations and is often associated with fetal hypoxemia due to insufficient placental perfusion.
Choice B rationale
The nurse should first place the client in the lateral position. This position can improve placental blood flow and may help to resolve the late decelerations.
Choice C rationale
Administering oxygen using a nasal cannula may be beneficial, but it is not the first action the nurse should take. The priority is to improve placental blood flow, which can be achieved by changing the client’s position.
Choice D rationale
Elevating the client’s legs is not the first action the nurse should take. This action would not directly address the issue of late decelerations.
Correct Answer is B
Explanation
Choice A rationale
Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.
Choice B rationale
Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.
Choice C rationale
Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.
Choice D rationale
Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.
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