You are caring for a patient who has a diagnosis of GI bleed. When you make your shift assessment, you find the patient is tachycardic and hypotensive. The patient has an episode of hematemesis while you are in the room
What would be a priority nursing action for this patient?
A) Put them in a high Fowler's position.
B) Give them ice water.
C) Assess for pain.
D) Notify the physician.
Ans: D
Feedback: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patient's vital signs are monitored as the patient's condition warrants. Putting the patient in a high Fowler's position is not a priority and neither is assessing for pain. Giving them ice water is contraindicated as it would stimulate more vomiting.
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Moisture reduces the effects of friction and shearing on the skin.
Answer the following statement true (T) or false (F)