A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?
Administer vasopressin to the client.
Request blood from blood bank.
Verify that the client has adequate IV access.
Insert an indwelling urinary catheter.
The Correct Answer is C
Verify that the client has adequate IV access.
Choice A rationale:
Administering vasopressin to the client might be necessary to manage the hemorrhage, but before any medication administration, it is crucial to ensure the client has adequate IV access. Vasopressin is a vasoconstrictor and can help control bleeding from esophageal varices, but its effectiveness relies on IV access to deliver the medication promptly.
Choice B rationale:
Requesting blood from the blood bank is essential for a client experiencing significant bleeding. However, the priority action is to verify IV access to administer any necessary blood products.
Choice C rationale:
This is the correct choice. Before initiating any interventions, ensuring the client has appropriate IV access is a priority. Adequate IV access is necessary to administer fluids, medications, or blood products promptly and effectively stabilize the client's blood pressure.
Choice D rationale:
Inserting an indwelling urinary catheter is not the priority action in this situation. While monitoring urine output is important, it should be secondary to addressing the client's hypotension and hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Crackles are adventitious lung sounds that can be heard on auscultation and are commonly associated with pneumonia. They are caused by the movement of air through fluid-filled or collapsed alveoli, indicating inflammation and infection in the lungs.
Choice B rationale:
Crepitus is a different respiratory finding and is not typically associated with pneumonia. Crepitus is a crackling or grating sensation that can be felt under the skin, often caused by subcutaneous emphysema or gas trapped in the tissues, not within the lungs.
Choice C rationale:
Stridor is a harsh, high-pitched sound heard during inspiration and is usually indicative of upper airway obstruction, not pneumonia. It can be caused by conditions such as croup or anaphylaxis.
Choice D rationale:
Decreased fremitus is not a specific manifestation of pneumonia. Fremitus is the vibration felt when the patient speaks and is transmitted through the chest wall. In pneumonia, increased fremitus may be observed due to the consolidation of lung tissue with fluid or pus, not decreased fremitus.
Correct Answer is D
Explanation
Choice A rationale:
Is not suitable for a client who has undergone a mastectomy with axillary lymph node dissection. This exercise may put a strain on the surgical site and cause discomfort or injury.
Choice B rationale:
Is also not appropriate for a postoperative mastectomy client. It involves using the left hand extensively, which could potentially disrupt the healing process and cause pain.
Choice C rationale:
Is not recommended for a postoperative mastectomy client. It involves significant upper body movement, which may not be well-tolerated after surgery, especially with lymph node dissection.
Choice D rationale:
This exercise is suitable for a postoperative mastectomy client as it helps in maintaining hand and arm mobility without putting excessive strain on the surgical site. It also aids in preventing complications like lymphedema, which is a potential concern after lymph node dissection.
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