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 D
Explanation
A. Avoiding eating at fast food restaurants is not a specific preventive measure for hepatitis A transmission. The primary mode of transmission for hepatitis A is through the fecal-oral route, often due to contaminated food or water.
B. Avoiding serving raw foods is a reasonable precaution as raw or undercooked shellfish and contaminated fruits and vegetables can be a source of hepatitis A transmission. However, practicing effective hand hygiene is a more general and fundamental preventive measure.
C. Wearing barrier protection during vaginal intercourse is not directly related to the prevention of hepatitis A. Hepatitis A is primarily transmitted through the fecal-oral route, and sexual transmission is not a common mode for this virus.
D. Practicing effective hand hygiene is a key strategy for preventing the transmission of hepatitis A. Proper handwashing with soap and water, especially after using the bathroom and before handling food, can help reduce the risk of contamination and transmission of the virus.
Correct Answer is ["A","B","D","E"]
Explanation
A. Is used to replace fluid loss.
Isotonic solutions, such as normal saline (0.9% NaCl) and lactated Ringer's solution, are used to replace fluid loss in situations such as dehydration, surgery, trauma, or other conditions where there is a need for fluid resuscitation.
B. Usually do not provide calories.
Isotonic solutions typically do not contain calories. They are designed primarily for fluid replacement and do not contribute to the nutritional needs of the patient.
C. Does not expand intravascular volume.
This statement is incorrect. Isotonic solutions are used to expand intravascular volume. When infused into the bloodstream, isotonic solutions help restore and maintain adequate blood volume. They do not cause significant shifts of fluids between compartments.
D. Mostly do not provide free water.
Isotonic solutions generally do not provide free water. They have the same osmolality as body fluids, meaning that they do not cause a net movement of water into or out of cells, and they maintain the osmotic balance.
E. Has the same osmolality as body fluids.
Isotonic solutions have the same osmolality as body fluids, which means they do not cause a net movement of water into or out of cells. This characteristic makes them suitable for situations where there is a need to expand intravascular volume without causing significant shifts in fluid compartments.
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