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 B
Explanation
Choice A rationale:
Increasing the intake of dairy products is not recommended for a client with irritable bowel syndrome (IBS) as dairy can exacerbate symptoms in some individuals, particularly if they are lactose intolerant.
Choice B rationale:
Drinking ten glasses of water each day is a helpful recommendation for clients with IBS. Staying hydrated can aid in digestion and help alleviate symptoms like constipation.
Choice C rationale:
Decreasing daily fiber intake to 20 grams is not advisable for IBS management. Adequate fiber intake is essential for maintaining bowel regularity and overall gut health. Instead, it is recommended to focus on soluble fiber and gradually increase fiber intake to avoid exacerbating symptoms.
Choice D rationale:
Encouraging the intake of clear carbonated fluids is not ideal for clients with IBS. Carbonated beverages can cause bloating and gas, potentially worsening symptoms in individuals with sensitive digestive systems. It is better to recommend non-carbonated, non-caffeinated fluids for hydration.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today