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
Epigastric discomfort is a common symptom of peptic ulcer disease, but it is not typically the symptom that should be prioritized. While discomfort can indicate an active ulcer, it does not necessarily signify a complication.
Choice B rationale
Hematemesis, or vomiting blood, is a serious symptom that could indicate a bleeding ulcer, which is a medical emergency. Therefore, this symptom should be prioritized.
Choice C rationale
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease. However, it is not typically the symptom that should be prioritized as it does not necessarily indicate a serious complication.
Choice D rationale
Constipation is not typically associated with peptic ulcer disease and therefore should not be prioritized.
Correct Answer is A
Explanation
Choice A rationale
Tremors are a common side effect of terbutaline. Terbutaline is a medication used to inhibit uterine contractions in preterm labor. It is a beta-adrenergic agonist, and stimulation of the beta-adrenergic receptors can lead to side effects such as tremors.
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