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.
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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Related Questions
Correct Answer is C
Explanation
A. Storing unopened bottles of insulin in the freezer is incorrect. Insulin should be stored in the refrigerator, and freezing can damage the insulin.
B. Having a morning blood glucose level between 200 and 230 is too high. The target range for fasting blood glucose is generally lower, and elevated levels may indicate the need for adjustment in insulin or other medications.
C. Eating a snack half an hour before playing soccer is a correct understanding. This helps prevent hypoglycemia during physical activity. Physical activity can lower blood glucose levels, and a pre-activity snack can provide additional carbohydrates to prevent low blood sugar.
D. Not taking regular insulin when sick is incorrect. In fact, insulin needs may increase during illness, and it is usually recommended to continue taking insulin even when sick. Adjustments to the insulin regimen may be needed under the guidance of healthcare providers.
Correct Answer is D
Explanation
A. Applying a cold pack to the client's upper arm is not the first action. The priority is to assess and address the cause of the edema. Cold packs may be used for comfort, but they do not address the underlying issue.
B. Removing the PICC line is not the first action. Before considering removal, it is essential to assess the extent and cause of the edema. Removing the line without proper evaluation could lead to premature discontinuation of necessary treatment.
C. Notifying the provider who inserted the PICC line is important, but it is not the first action. The nurse needs to assess and intervene promptly. The provider should be informed after initial actions are taken.
D. Stopping the infusion and measuring the circumference of both upper arms is the first action. This helps determine the extent of the edema and whether it is related to the infusion. It is crucial to assess for complications such as infiltration or extravasation of the TPN solution.
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