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 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.

A. Limit fluid intake not related to meals. B. Avoid eating within 3 hr of bedtime C. Chew on mint leaves to relieve indigestion. D. Season foods with black pepper.

Correct Answer is B

Explanation

A. Limit fluid intake not related to meals:

While staying hydrated is important, it's generally recommended to limit fluid intake not related to meals to avoid overfilling the stomach and putting excess pressure on the lower esophageal sphincter (LES). However, this is not as specific to GERD management as the option B.

B. Avoid eating within 3 hours of bedtime:

This is a key recommendation for managing GERD. Eating close to bedtime increases the likelihood of stomach contents refluxing into the esophagus when lying down. Waiting at least 3 hours after eating before lying down can help prevent symptoms.

C. Chew on mint leaves to relieve indigestion:

Mint, including mint leaves, can relax the LES, potentially worsening GERD symptoms. It is not recommended for managing GERD.

D. Season foods with black pepper:

While black pepper itself is not a common trigger for GERD, highly spicy or peppery foods can sometimes exacerbate symptoms in individuals with GERD. It's advisable to pay attention to personal triggers and adjust the diet accordingly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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