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 D

Explanation

Choice A rationale

Betamethasone, a corticosteroid, is not known to weaken uterine contractions. It is often administered to pregnant women at risk of preterm delivery to enhance fetal lung maturation and reduce complications associated with prematurity.

Choice B rationale

Betamethasone can potentially increase blood glucose levels, not decrease them. This is particularly relevant in women with gestational diabetes, as corticosteroids can exacerbate hyperglycemia.

Choice C rationale

Betamethasone does not typically decrease the fetal heart rate. Instead, it is used to help mature the lungs of the fetus.

Choice D rationale

Betamethasone is administered to pregnant women at risk of preterm delivery to enhance the production of surfactant in the fetal lungs. Surfactant is a substance that prevents the small air sacs in the lungs from collapsing, thereby aiding in the baby’s ability to breathe after birth.

A. Two veins and one artery B. Two arteries and one vein C. One artery and one vein D. Two arteries and two veins

Correct Answer is B

Explanation

Choice B rationale

The umbilical cord normally contains two arteries and one vein. The arteries carry deoxygenated blood and waste products from the fetus to the placenta, and the vein carries oxygenated blood and nutrients from the placenta to the fetus.

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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?

Nursing Test Bank

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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?