Safe, Effective Care Environment
72. A night RN reports that a client, admitted with a diagnosis of gastric ulcer, is reporting syncope and dizziness. What should be the initial nursing intervention by the RN?
Safe, Effective Care Environment
72. A night RN reports that a client, admitted with a diagnosis of gastric ulcer, is reporting syncope and dizziness. What should be the initial nursing intervention by the RN?
. Keep the client on bedrest.
. Call for a STAT Hgb and Hct.
. Give a STAT dose of sucralfate (Carafate).
. Check the client's vital signs.
Test-Taking Tip
The key word is "initial"; safety is the priority with a client complaining of syncope and vertigo.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
.
Answer 1 is correct because the priority is to maintain client safety. With syncope and dizziness, the client is at high risk for falling. Answer 2 is incorrect because, although a current hemoglobin (Hgb) and hematocrit (Hct) would be important data to assess for bleeding, these tests are not the highest priority. Answer 3 is incorrect because sucralfate (Carafate) is primarily prescribed for the short-term management of duodenal, not gastric, ulcers. Answer 4 is incorrect because, although vital signs are an important assessment, especially with syncope and dizziness, safety is the priority in this situation, followed by further assessment.