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 D
Explanation
Choice A rationale:
The nurse should not instruct the older adult client with osteoporosis to increase high-impact activities. Osteoporosis is a condition characterized by decreased bone density and strength, making high-impact activities potentially harmful as they could increase the risk of fractures.
Choice B rationale:
The nurse should not advise the client to consume a low-protein diet. Adequate protein intake is essential for maintaining muscle mass and overall musculoskeletal health, especially in older adults who may be at risk of muscle wasting.
Choice C rationale:
The nurse should not encourage the client to maintain a BMI of 30 to 35. A BMI within this range is considered obese and can put additional stress on the musculoskeletal system, increasing the risk of joint problems and other health issues.
Choice D rationale:
Including fiber in the diet is a correct instruction for promoting musculoskeletal health. Fiber-rich foods can help maintain bowel regularity and prevent constipation, which is important for overall comfort and mobility in older adults with osteoporosis.
Correct Answer is B
Explanation
Choice A rationale:
Is not a safe fall prevention strategy. Securing cords under carpeting can create tripping hazards. It is better to keep cords away from commonly used walking paths or use cord covers to prevent falls.
Choice B rationale:
Purchasing a skid-proof bathtub mat is a good fall-prevention strategy for an older adult client. It helps prevent slipping and falling in the bathroom, which is a common area for accidents in older adults.
Choice C rationale:
Is not a recommended fall prevention strategy. Leather soles can be slippery on smooth surfaces, increasing the risk of falls. Instead, the client should wear shoes with rubber soles that provide better traction.
Choice D rationale:
Is not the best option. Throw rugs, even with rubber backing, can still shift or bunch up, posing a tripping hazard. It's safer to avoid using throw rugs altogether or ensure they are firmly secured to the floor.
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