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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Increase physical activity and daily exercise.
Regular physical activity helps improve insulin sensitivity, manage blood glucose levels, and lower the risk of cardiovascular complications associated with diabetes.
B. Reduce cholesterol and saturated fat intake.
Managing cholesterol levels and reducing saturated fat intake can help lower the risk of cardiovascular disease, which is a common complication of diabetes.
C. Maintain optimal blood pressure to prevent kidney damage.
Controlling and maintaining blood pressure within optimal ranges is crucial in preventing kidney damage, a common complication of diabetes.
D. Enroll in a smoking-cessation program.
Smoking increases the risk of cardiovascular complications and can exacerbate other diabetes-related health issues. Quitting smoking is important in reducing the risk of complications.
E. Sustain hyperglycemia to reduce deterioration of nerve cells.
Sustaining hyperglycemia (high blood sugar levels) is detrimental and contributes to the progression of diabetic complications, including nerve damage (neuropathy). Lowering and controlling blood glucose levels are essential in preventing complications rather than sustaining hyperglycemia.
Correct Answer is A
Explanation
A. Avoid foods high in fat:
Dietary fat can trigger the gallbladder to release bile, and for individuals with chronic cholecystitis, high-fat meals can exacerbate symptoms such as biliary colic. Therefore, advising the client to avoid foods high in fat can help manage symptoms.
B. Include foods high in starch and proteins:
While protein-rich foods can be included in the diet, a high-fat content should be avoided. Starches can be a part of a balanced diet, but it's essential to focus on low-fat options.
C. Include foods high in fiber:
Including foods high in fiber is generally a good recommendation for digestive health. However, the emphasis here is on avoiding high-fat foods, and the recommendation for fiber should not overshadow the importance of minimizing dietary fat.
D. Avoid foods high in sodium:
Sodium restriction may be relevant for certain health conditions, but it is not the primary dietary consideration for managing chronic cholecystitis. The emphasis in this context is on reducing dietary fat.
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