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 C
Explanation
C. Fever:
Fever is a classic sign of fat overload syndrome. Fat overload syndrome occurs when the body is unable to metabolize the fat in the IV fat emulsion properly, leading to fat accumulation in tissues and organs. This can result in fever, which is one of the primary manifestations. Other signs can include respiratory distress, liver dysfunction, and changes in laboratory values, such as elevated triglycerides.
Correct Answer is C
Explanation
Choice A rationale:
This statement indicates the client's fear and concern about the colostomy's odor, showing a lack of adaptation to the situation.
Choice B rationale:
Comparing the stoma to a strawberry with a hole in it might suggest the client is not fully accepting or understanding the colostomy, indicating a lack of adaptation.
Choice C rationale:
This statement suggests that the client has delegated the task of emptying the colostomy bag to their partner, which indicates a level of acceptance and adaptation to the new situation.
The client trusts their partner with this intimate task, demonstrating a positive sign of adaptation.
Choice D rationale:
Eliminating many foods from the diet suggests difficulty in adjusting to the dietary changes required for managing a colostomy, indicating a lack of full adaptation.
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