The nurse is concerned that a patient being treated for an acute upper gastrointestinal bleed is experiencing poor tissue perfusion because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are
selected. Select all that apply. 1. Flat jugular veins
2. Cold clammy skin
3. Capillary refill of 5 seconds
4. Narrowed pulse pressure
5. Bounding peripheral pulses
1,2,3,4
Rationale 1: Flat jugular veins indicate poor tissue perfusion in the patient with an acute gastrointestinal bleed.
Rationale 2: Cold clammy skin indicates poor tissue perfusion in the patient with an acute gastrointestinal bleed.
Rationale 3: A capillary refill of greater than 3 seconds indicates poor tissue perfusion in the patient with an acute gastrointestinal bleed.
Rationale 4: Narrowed pulse pressure indicates poor tissue perfusion in the patient with an acute gastrointestinal bleed.
Rationale 5: Bounding peripheral pulses indicates adequate or over hydration in the patient with an acute gastrointestinal bleed.
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