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. Calcium:
While calcium levels can be affected in pancreatitis, it is more commonly associated with a decrease in calcium levels due to fat necrosis and the formation of calcium soaps. However, the primary electrolyte disturbance is more likely to involve magnesium.
B. Magnesium:
Magnesium levels may be decreased in acute pancreatitis due to factors such as vomiting, malabsorption, and poor oral intake. Hypomagnesemia is a possible consequence, but it's not as specific to pancreatitis as the elevation of amylase.
C. Amylase:
Elevated amylase levels are a hallmark of acute pancreatitis. Amylase is an enzyme released by the pancreas, and its elevation in the blood is a key diagnostic marker for pancreatitis.
D. RBC count:
Acute pancreatitis does not typically result in a significant impact on the red blood cell (RBC) count. The elevation of amylase and lipase levels, along with imaging studies, is more indicative of pancreatitis.
Correct Answer is D
Explanation
A. Applying a cold pack to the client's upper arm is not the first action. The priority is to assess and address the cause of the edema. Cold packs may be used for comfort, but they do not address the underlying issue.
B. Removing the PICC line is not the first action. Before considering removal, it is essential to assess the extent and cause of the edema. Removing the line without proper evaluation could lead to premature discontinuation of necessary treatment.
C. Notifying the provider who inserted the PICC line is important, but it is not the first action. The nurse needs to assess and intervene promptly. The provider should be informed after initial actions are taken.
D. Stopping the infusion and measuring the circumference of both upper arms is the first action. This helps determine the extent of the edema and whether it is related to the infusion. It is crucial to assess for complications such as infiltration or extravasation of the TPN solution.
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