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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instruct the client that they can lift over 20 lbs:
Lifting heavy objects should be avoided postoperatively to prevent strain on the surgical site. The specific weight restriction may vary, but lifting heavy objects is generally discouraged.
B. Offer the client ice cream postoperatively:
While offering ice cream may be a comforting measure, it is not a specific action related to the recovery from a laparoscopic cholecystectomy.
C. Encourage ambulation once fully awake:
This is the correct action. Encouraging ambulation helps prevent complications such as blood clots and promotes recovery after laparoscopic surgery. Early mobility is generally encouraged unless contraindicated for specific reasons.
D. Place the client in a supine position postoperatively:
The position of the client postoperatively depends on the specific surgical procedure and the surgeon's preferences. However, placing the client in a supine position alone is not a comprehensive postoperative care action.
Correct Answer is C
Explanation
A. Positioning the client on the right side is not a standard recommendation for gastric lavage. The standard position is typically on the left side to facilitate the drainage of gastric contents.
B. Instilling 1000 mL of sterile saline is not a recommended action for gastric lavage. Gastric lavage involves the removal of stomach contents rather than instilling fluids.
C. Withdrawing fluid until it is clear is the correct action. Gastric lavage is a medical procedure used to empty the stomach contents. The process involves introducing small amounts of fluid (such as saline) into the stomach and then aspirating it back, along with gastric contents, until the aspirate is clear.
D. Connecting the NG tube to high continuous suction is not a standard approach for gastric lavage. Gastric lavage involves intermittent instillation and withdrawal of small amounts of fluid to clear the stomach.
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