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.

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Correct Answer is C

Explanation

Choice A rationale

Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.

Choice B rationale

Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.

Choice C rationale

Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.

Choice D rationale

Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.

A. Ask the partner to talk about his difficulties in caring for the client. B. Recommend that the partner place the client in a long-term care facility. C. Tell the partner to call a family meeting to get help. D. Suggest that the partner see a counselor to help him cope with his exhaustion.

Correct Answer is A

Explanation

Choice A rationale

Asking the partner to talk about his difficulties in caring for the client is the nurse’s priority. This intervention allows the nurse to assess the partner’s emotional state and provide appropriate support and resources.

Choice B rationale

Recommending that the partner place the client in a long-term care facility may not be the best initial intervention. The decision to place a loved one in a long-term care facility is complex and involves many factors. The nurse should first assess the partner’s needs and concerns before making such a recommendation.

Choice C rationale

Telling the partner to call a family meeting to get help may be a helpful suggestion, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.

Choice D rationale

Suggesting that the partner see a counselor to help him cope with his exhaustion may be a helpful intervention, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.

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

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Explanation

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Explanation

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