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 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
Explanation
A. Tremors:
Tremors or shaking is a common symptom of hypoglycemia. When blood glucose levels drop too low, the body reacts by releasing hormones like adrenaline, leading to symptoms such as tremors, shakiness, and palpitations.
B. Bradycardia:
Bradycardia, or a slow heart rate, is not typically associated with hypoglycemia. Instead, hypoglycemia tends to stimulate the release of adrenaline, which can increase heart rate.
C. Vomiting:
Vomiting is not a classic manifestation of hypoglycemia. Nausea may occur, but vomiting is more commonly associated with conditions such as hyperglycemia or diabetic ketoacidosis.
D. Fruity odor on the client’s breath:
A fruity odor on the breath is more commonly associated with diabetic ketoacidosis (DKA) in individuals with diabetes mellitus, particularly when there is an accumulation of ketones in the body. It is not a typical manifestation of hypoglycemia.
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