NCLEX RN Practice Question # 698
NCLEX Examination.
Practice Question # 698.
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1. Question
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?
CorrectAnswer: Option 1 is the correct answer.
Rationale: The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a health care provider’s prescription; in addition, the vital signs should be checked before performing this procedure.
Test-Taking Strategy: Note the strategic word, priority, and use the ABCs—airway–breathing–circulation. Thiswill direct you to the correct option.IncorrectAnswer: Option 1 is the correct answer.
Rationale: The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a health care provider’s prescription; in addition, the vital signs should be checked before performing this procedure.
Test-Taking Strategy: Note the strategic word, priority, and use the ABCs—airway–breathing–circulation. Thiswill direct you to the correct option.
There are four (4) types of Vital Signs you should Monitor for client`s assessment.
- Heart Rate
- Respirations
- Blood Pressure
- Temperature
Following are the normal ranges of vital signs.
