A patient, being treated for acute gastrointestinal bleeding, is receiving 0.9% normal saline at 200 mL/hour through two large-bore IVs. What assessment finding would the nurse report immediately to the physician?

Question

1. Crackles in both lung bases
2. Urinary output of 50 mL in 1 hour
3. Capillary refill of less than 2 seconds
4. Approximately 200 mL of coffee ground emesis

Answer 1

1
Rationale 1: Crackles on auscultation of the lungs suggest fluid overload and should be immediately reported to the physician.
Rationale 2: Urinary output of 50 mL/hour indicates the fluid volume resuscitation has been successful and that renal perfusion has been maintained.
Rationale 3: A capillary refill of less than 2 seconds is a normal finding indicating adequate perfusion.
Rationale 4: The presence of coffee ground emesis indicates slowed or stopped bleeding.