A nurse is caring for a patient who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

Assess orthostatic blood pressure.

Administer pain medication.

Explain the procedure for an upper gastrointestinal series.

Test the patient’s emesis for blood.

Answer and Explanation

The Correct Answer is A

The first action the nurse should take when caring for a patient with gastrointestinal bleeding is to assess orthostatic blood pressure. This can help determine the extent of the patient’s blood loss and whether they are experiencing hypovolemia.

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Correct Answer is C

Explanation

Choice A rationale

Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.

Choice B rationale

Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.

Choice C rationale

Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.

Choice D rationale

Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.

Correct Answer is ["120"]

Explanation

The correct answer is 120 gtt/min.

Step 1 is to convert the infusion rate from mL/hr to mL/min: 120 mL/hr ÷ 60 min/hr = 2 mL/min.

Step 2 is to multiply the mL/min rate by the drop factor to find the gtt/min rate: 2 mL/min × 60 gtt/mL = 120 gtt/min.

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A nurse is caring for a patient who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is in the process of taking a patient’s oral temperature.The patient informs the nurse that they have just consumed some ice chips. What should the nurse do next?

Correct Answer is C

Explanation

Correct Answer is ["120"]

Explanation

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