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 B rationale
When a couple is found to be carriers of an autosomal-recessive disorder, one of the actions the nurse can take is to discuss options with the couple, including amniocentesis to determine if their fetus is affected. This procedure can provide definitive information about the genetic status of the fetus, allowing the couple to make informed decisions about the pregnancy.
Correct Answer is B
Explanation
Choice A rationale
A recent history of stressful, positive life events is not a primary risk factor for depression. While any significant life change can trigger stress and potentially contribute to depression, it is typically negative or traumatic events that are most strongly associated with an increased risk of depression.
Choice B rationale
Being male and over the age of 80 is a primary risk factor for depression. Older adults, particularly those with chronic medical conditions, are at an increased risk of depression. Additionally, while women are more likely than men to experience depression at younger ages, the gender gap narrows with age.
Choice C rationale
Being an only child is not a primary risk factor for depression. While family history can play a role in depression risk, it is typically a history of depression in first-degree relatives that is most strongly associated with an increased risk.
Choice D rationale
Having elevated levels of serotonin is not a primary risk factor for depression. In fact, it is typically low levels of serotonin that are associated with an increased risk of depression. Informed consent Explore
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