A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?

Elevate the client’s feet.

Administer a unit of packed RBCs.

Initiate a dopamine IV infusion for the client.

Increase the client’s IV ﬂuid rate.

Answer and Explanation

The Correct Answer is D

Choice a) is incorrect because elevating the client’s feet is not the priority action for a hypotensive client. Elevating the client’s feet may help increase the venous return to the heart, but it may also compromise the respiratory status of a client who has esophageal varices and is at risk of aspiration.

Choice b) is incorrect because administering a unit of packed RBCs is not the priority action for a hypotensive client. Administering a unit of packed RBCs may help increase the oxygen-carrying capacity of the blood, but it may also increase the blood viscosity and pressure, which can worsen the bleeding from the esophageal varices.

Choice c) is incorrect because initiating a dopamine IV infusion for the client is not the priority action for a hypotensive client. Initiating a dopamine IV infusion may help increase the blood pressure and cardiac output, but it may also cause vasoconstriction and tachycardia, which can increase the risk of hemorrhage and arrhythmias.

Choice d) is correct because increasing the client’s IV ﬂuid rate is the priority action for a hypotensive client. Increasing the client’s IV ﬂuid rate may help restore the intravascular volume and perfusion, which can prevent shock and organ damage. Increasing the client’s IV ﬂuid rate may also dilute the blood and reduce its viscosity and pressure, which can decrease the bleeding from the esophageal varices.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.

Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.

Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.

Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.

A. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around D. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because this client has signs of brain death, such as severe head injuries, low respiratory rate, and unresponsiveness. The nurse should tag this client as black, which means deceased or expectant.

Choice B Reason: This is incorrect because this client has non-life-threatening injuries, such as a simple fracture and scratches. The nurse should tag this client as green, which means minor or delayed care.

Choice C Reason: This is incorrect because this client has minor injuries and is able to walk around. The nurse should tag this client as green, which means minor or delayed care.

Choice D Reason: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. This client has a life-threatening condition called tension pneumothorax, which is caused by air leaking into the pleural space and compressing the lung and the heart. This can lead to respiratory failure, cardiac arrest, and death if not treated immediately. The hissing sound indicates that air is escaping from the lung through the wound. The nurse should tag this client as red, which means immediate care is needed.

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A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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