The nurse has been assigned to provide care for several patients on the medical-surgical unit. After reviewing the data exchanged during the shift report, which patient should the nurse plan to assess first? The patient with:

Question

1. An elevated temperature of 99.2°F and complaints of nausea
2. Complaints of feelings of fullness and no bowel movement for 2 days
3. A heart rate of 82 bpm, complaints of fatigue, and an episode of coffee ground emesis 4 hours ago
4. Two episodes of melena diarrhea within the past 2 hours

Answer 1

4
Rationale 1: The presence of a mildly elevated temperature of 99.2°F and complaints of nausea, although uncomfortable for the patient, do not indicate the presence of an immediate problem.
Rationale 2: Feelings of fullness and the lack of a bowel movement are consistent with constipation and warrant action but is not a priority.
Rationale 3: The patient's heart rate of 82 bpm signal that the patient is not in immediate danger. The presence of coffee ground emesis may signal slowed or halted bleeding.
Rationale 4: The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse.