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

Test the client's emesis for blood.

Assess orthostatic blood pressure.

Explain the procedure for an upper gastrointestinal series.

Administer pain medication.

Answer and Explanation

The Correct Answer is B

A. Testing the client's emesis for blood is an important assessment, but assessing orthostatic blood pressure is a priority. Orthostatic blood pressure measurement helps identify if the client is experiencing significant blood loss, as changes in blood pressure upon standing may indicate hypovolemia.

B. Assessing orthostatic blood pressure is the priority action. Orthostatic hypotension can be a sign of decreased circulating blood volume, which is a concern in clients with gastrointestinal bleeding.

C. Explaining the procedure for an upper gastrointestinal series is not the first priority. While diagnostic tests may be needed, addressing the immediate concern of potential hypovolemia takes precedence.

D. Administering pain medication is not the first action. The priority is to assess and address the potential complications of gastrointestinal bleeding, such as hypovolemia.

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Correct Answer is B

Explanation

A. Hepatitis A does not infect the kidneys. Hepatitis A is a viral infection that primarily affects the liver, causing inflammation.

B. Manifestations of hepatitis A are indeed similar to flu-like symptoms. Common symptoms include fever, fatigue, nausea, vomiting, abdominal pain, loss of appetite, and jaundice (yellowing of the skin and eyes).

C. The incubation period for hepatitis A is typically 15 to 50 days, not 5 days. The incubation period is the time between exposure to the virus and the onset of symptoms.

D. A family history is not a significant risk factor for acquiring hepatitis A. Hepatitis A is primarily transmitted through the fecal-oral route, often due to contaminated food or water. It is more commonly associated with exposure to the virus through contaminated environments or ingestion of contaminated food or water.

A. The charge nurse should follow the staff closely and tell them every single thing they could possibly be doing wrong. B. Make the staff aware that all errors will be severely punished. C. Acknowledge staff accomplishments when warranted and provide positive feedback. D. Provide negative feedback with all errors.

Correct Answer is C

Explanation

A. The charge nurse should follow the staff closely and tell them every single thing they could possibly be doing wrong:

Micromanaging and focusing solely on the negatives can create a stressful and demoralizing work environment. This approach is less likely to motivate and inspire staff.

B. Make the staff aware that all errors will be severely punished:

A punitive approach to errors can create a culture of fear and may not foster a supportive environment for learning and improvement. It can lead to decreased morale and job satisfaction.

C. Acknowledge staff accomplishments when warranted and provide positive feedback:

This is the most effective approach. Recognizing and acknowledging staff achievements, providing positive feedback, and celebrating successes contribute to a positive work environment. It motivates staff to continue their efforts and fosters a culture of teamwork and collaboration.

D. Provide negative feedback with all errors:

While constructive feedback is essential for learning and improvement, a balance between constructive criticism and positive reinforcement is crucial. Constant negative feedback without recognition of positive efforts can lead to decreased morale.

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

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